MEDICARE: DR. LARS OLAV BOUMA DDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	PROSTHODONTICS 30	OK
2	1223G0001X	General Practice Dentistry	18073	TX

General Provider Information

NPI Number	:	1588658470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARS OLAV BOUMA DDS, MS

Provider Business Mailing Address
First Line	:	4604 NW 161ST ST
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-3250
Country	:	US
Telephone Number	:	405-285-5937
Fax Number	:

Provider Business Practice Location Address
First Line	:	4517 MEMORIAL CIR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-5004
Country	:	US
Telephone Number	:	405-755-7777
Fax Number	:	405-755-7169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	09/11/2025

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