Provider Demographics
NPI:1588658470
Name:BOUMA, LARS OLAV (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:OLAV
Last Name:BOUMA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 NW 161ST ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3250
Mailing Address - Country:US
Mailing Address - Phone:405-285-5937
Mailing Address - Fax:
Practice Address - Street 1:4517 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-5004
Practice Address - Country:US
Practice Address - Phone:405-755-7777
Practice Address - Fax:405-755-7169
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPROSTHODONTICS 301223P0700X
TX180731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0700XDental ProvidersDentistProsthodontics
Not Answered1223G0001XDental ProvidersDentistGeneral Practice