Provider Demographics
NPI:1346548369
Name:OWASSO ORTHODONTICS
Entity Type:Organization
Organization Name:OWASSO ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-272-4242
Mailing Address - Street 1:12813 E 101ST PL N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4662
Mailing Address - Country:US
Mailing Address - Phone:918-272-4242
Mailing Address - Fax:918-272-5753
Practice Address - Street 1:12813 E 101ST PL N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4662
Practice Address - Country:US
Practice Address - Phone:918-272-4242
Practice Address - Fax:918-272-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200048910AMedicaid