Provider Demographics
NPI:1174673396
Name:FOERSTER WENDELKEN, LARA J (DDS)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:J
Last Name:FOERSTER WENDELKEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MY DENTIST 1900 S. AIR DEPOT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-5522
Mailing Address - Country:US
Mailing Address - Phone:405-455-1534
Mailing Address - Fax:405-455-1513
Practice Address - Street 1:MY DENTIST 1900 S. AIR DEPOT
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-5522
Practice Address - Country:US
Practice Address - Phone:405-455-1534
Practice Address - Fax:405-455-1513
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice