Provider Demographics
NPI:1629110119
Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU DENITSTRY
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU DENITSTRY
Other - Org Name:UNIVERSITY DENTAL FACULTY GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:D.
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-8001
Mailing Address - Street 1:PO BOX 528802-8802
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73152-8802
Mailing Address - Country:US
Mailing Address - Phone:405-271-5714
Mailing Address - Fax:405-271-2405
Practice Address - Street 1:1201 N STONEWALL
Practice Address - Street 2:ROOM 494
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1214
Practice Address - Country:US
Practice Address - Phone:405-271-5714
Practice Address - Fax:405-271-2405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100745050AMedicaid