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Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
D.D.S.

Contact information

Practice address
1702 PARK HILL RD, TAHLEQUAH, OK 74464-5600
(918) 456-3082
(918) 456-3536
Mailing address
1702 PARK HILL RD, TAHLEQUAH, OK 74464-5600
(918) 456-3082
(918) 456-3536

Taxonomy

Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5234
OK

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
100091210A
OK
Enumeration date
04/23/2007
Last updated
11/14/2013
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