Provider Demographics
NPI:1467627364
Name:CENTRAL OKLAHOMA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:CENTRAL OKLAHOMA ORAL & MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:PHARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-624-1300
Mailing Address - Street 1:812 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4349
Mailing Address - Country:US
Mailing Address - Phone:405-624-1300
Mailing Address - Fax:405-624-3084
Practice Address - Street 1:812 S PINE ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4349
Practice Address - Country:US
Practice Address - Phone:405-624-1300
Practice Address - Fax:405-624-3084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty