Provider Demographics
NPI:1487074704
Name:EASTERN OKLAHOMA ORAL AND MAXILLOFACIAL SURGEONS
Entity type:Organization
Organization Name:EASTERN OKLAHOMA ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND CONTRACTING
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-247-1869
Mailing Address - Street 1:4716 W URBANA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5997
Mailing Address - Country:US
Mailing Address - Phone:918-449-5800
Mailing Address - Fax:918-455-8958
Practice Address - Street 1:4716 W URBANA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5997
Practice Address - Country:US
Practice Address - Phone:918-449-5800
Practice Address - Fax:918-455-8958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200537790AMedicaid
OK200537790BMedicaid