Provider Demographics
NPI:1114287091
Name:ON THE CUSP PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:ON THE CUSP PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:918-970-4944
Mailing Address - Street 1:8222 E 103RD ST
Mailing Address - Street 2:133
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7081
Mailing Address - Country:US
Mailing Address - Phone:918-970-4944
Mailing Address - Fax:918-970-4593
Practice Address - Street 1:8222 E 103RD ST STE 133
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7027
Practice Address - Country:US
Practice Address - Phone:918-970-4944
Practice Address - Fax:918-970-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200258530AMedicaid