Provider Demographics
NPI:1457678039
Name:WEST TULSA DENTAL CENTER
Entity Type:Organization
Organization Name:WEST TULSA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-352-3312
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:DRUMRIGHT
Mailing Address - State:OK
Mailing Address - Zip Code:74030-0712
Mailing Address - Country:US
Mailing Address - Phone:918-352-3312
Mailing Address - Fax:918-352-2681
Practice Address - Street 1:5031 S 33RD WEST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-7409
Practice Address - Country:US
Practice Address - Phone:918-352-3312
Practice Address - Fax:918-352-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty