Provider Demographics
NPI:1619941242
Name:WOMACK, BOB H (DDS)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:H
Last Name:WOMACK
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 1:18563 305TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEOTA
Mailing Address - State:OK
Mailing Address - Zip Code:74941-6513
Mailing Address - Country:US
Mailing Address - Phone:918-966-3827
Mailing Address - Fax:
Practice Address - Street 1:109 STANLY RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OK
Practice Address - Zip Code:74536
Practice Address - Country:US
Practice Address - Phone:918-569-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1516122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1305466Medicaid