Provider Demographics
NPI:1437445400
Name:SPARKMAN, BEAU E (DDS)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:E
Last Name:SPARKMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W RAY FINE BLVD
Mailing Address - Street 2:STE. 5
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5289
Mailing Address - Country:US
Mailing Address - Phone:918-503-6262
Mailing Address - Fax:918-913-4595
Practice Address - Street 1:104 W RAY FINE BLVD
Practice Address - Street 2:STE. 5
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5289
Practice Address - Country:US
Practice Address - Phone:918-503-6262
Practice Address - Fax:918-913-4595
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38331223G0001X
OK63471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice