Provider Demographics
NPI:1477044410
Name:AHLBORN, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:AHLBORN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6440
Mailing Address - Country:US
Mailing Address - Phone:580-622-6655
Mailing Address - Fax:
Practice Address - Street 1:1808 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-4246
Practice Address - Country:US
Practice Address - Phone:801-636-8716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist