Provider Demographics
NPI:1053635615
Name:ROBERT L MIRACLE, DMD, PC
Entity Type:Organization
Organization Name:ROBERT L MIRACLE, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRACLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:580-355-1314
Mailing Address - Street 1:1810 NW FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5625
Mailing Address - Country:US
Mailing Address - Phone:580-355-1314
Mailing Address - Fax:580-355-1027
Practice Address - Street 1:1810 NW FERRIS AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-5625
Practice Address - Country:US
Practice Address - Phone:580-355-1314
Practice Address - Fax:580-355-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4 5347261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100124580BMedicaid