Provider Demographics
NPI:1306839246
Name:SOUTHEAST OKLAHOMA ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:SOUTHEAST OKLAHOMA ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R.
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-332-3010
Mailing Address - Street 1:803 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7711
Mailing Address - Country:US
Mailing Address - Phone:580-332-3010
Mailing Address - Fax:580-332-3010
Practice Address - Street 1:803 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7711
Practice Address - Country:US
Practice Address - Phone:580-332-3010
Practice Address - Fax:580-332-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK444583300004OtherBCBS
OK444583300003OtherBCBS
OK787600OtherUNITED CONCORDIA
OK100112550AMedicaid
OK444583300004OtherBCBS
OK787600OtherUNITED CONCORDIA