Individual
GARY E THEOBALD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
2619 S ELM PL, BROKEN ARROW, OK 74012-7878
(918) 455-0811
(918) 451-4787
Mailing address
2619 S ELM PL, BROKEN ARROW, OK 74012-7878
(918) 455-0811
(918) 451-4787
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
3804
OK
Other
Enumeration date
02/20/2007
Last updated
07/08/2007
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