Provider Demographics
NPI:1487875258
Name:UNIVERSITY ORAL & MAXILLO FACIAL SURGEONS
Entity type:Organization
Organization Name:UNIVERSITY ORAL & MAXILLO FACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MAXILLOFACIAL PROS
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLASSERIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:405-271-5744
Mailing Address - Street 1:PO BOX 26901
Mailing Address - Street 2:DCS209
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73190-0001
Mailing Address - Country:US
Mailing Address - Phone:405-271-5744
Mailing Address - Fax:405-271-4181
Practice Address - Street 1:1201 N STONEWALL AVE
Practice Address - Street 2:RM 418A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-5744
Practice Address - Fax:405-271-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty