Provider Demographics
NPI:1568191096
Name:BARTLESVILLE ORAL SURGERY, PLLC
Entity Type:Organization
Organization Name:BARTLESVILLE ORAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DERRICK
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-333-9155
Mailing Address - Street 1:215 SE HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006
Mailing Address - Country:US
Mailing Address - Phone:918-333-9155
Mailing Address - Fax:918-333-9142
Practice Address - Street 1:215 SE HOWARD AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006
Practice Address - Country:US
Practice Address - Phone:918-333-9155
Practice Address - Fax:918-333-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty