Provider Demographics
NPI:1326273996
Name:TULSA DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:TULSA DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:JUDY
Authorized Official - Last Name:MADAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-627-3900
Mailing Address - Street 1:5151 E 51ST ST STE 102
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7450
Mailing Address - Country:US
Mailing Address - Phone:918-627-3900
Mailing Address - Fax:918-627-7077
Practice Address - Street 1:5151 E 51ST ST
Practice Address - Street 2:SUITE 102
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7457
Practice Address - Country:US
Practice Address - Phone:918-627-3900
Practice Address - Fax:918-627-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3173251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare