Provider Demographics
NPI:1033252937
Name:MENDENHALL, JACOB WILLIAM BUSTER (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM BUSTER
Last Name:MENDENHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 HEFNER POINTE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5082
Mailing Address - Country:US
Mailing Address - Phone:405-463-0004
Mailing Address - Fax:405-463-0010
Practice Address - Street 1:10900 HEFNER POINTE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5082
Practice Address - Country:US
Practice Address - Phone:405-463-0044
Practice Address - Fax:405-463-0010
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5823204E00000X
OK1481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200185210AMedicaid