MEDICARE: ENDODONTIC SPECIALISTS OF NORTHEAST OK

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	1223E0200X	Endodontics	5644	OK

General Provider Information

NPI Number	:	1790951614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDODONTIC SPECIALISTS OF NORTHEAST OK

Provider Business Mailing Address
First Line	:	5555 E 71ST ST
Second Line	:	STE 9210
City	:	TULSA
State	:	OK
Zip	:	74136-6542
Country	:	US
Telephone Number	:	918-524-3366
Fax Number	:	918-524-3399

Provider Business Practice Location Address
First Line	:	5555 E 71ST ST
Second Line	:	STE 9210
City	:	TULSA
State	:	OK
Zip	:	74136-6542
Country	:	US
Telephone Number	:	918-524-3366
Fax Number	:	918-524-3399

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ARMELLA GLENN
Credential	:	BS
Telephone Number	:	918-524-3366

Provider Enumeration Date	:	04/30/2008
Last Update Date	:	04/30/2008

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