Provider Demographics
NPI:1942521687
Name:FOOTHILLS ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:FOOTHILLS ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WINKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:918-457-9779
Mailing Address - Street 1:29062 S 558 RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-2876
Mailing Address - Country:US
Mailing Address - Phone:918-457-9779
Mailing Address - Fax:918-457-5761
Practice Address - Street 1:1500 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-456-0671
Practice Address - Fax:918-457-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty