Provider Demographics
NPI:1164798757
Name:HERO DENTAL OF TULSA PC
Entity Type:Organization
Organization Name:HERO DENTAL OF TULSA PC
Other - Org Name:ADVENTURE DENTAL OF TULSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRYHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-576-1850
Mailing Address - Street 1:15 N NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1708
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-576-1929
Practice Address - Street 1:4955 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-0000
Practice Address - Country:US
Practice Address - Phone:719-576-1850
Practice Address - Fax:719-576-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty