Provider Demographics
NPI:1629744685
Name:SOUTHERN POINTE DENTAL AND IMPLANTS LLC
Entity Type:Organization
Organization Name:SOUTHERN POINTE DENTAL AND IMPLANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-260-6080
Mailing Address - Street 1:6139 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-3104
Mailing Address - Country:US
Mailing Address - Phone:918-492-8577
Mailing Address - Fax:
Practice Address - Street 1:6139 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-3104
Practice Address - Country:US
Practice Address - Phone:918-492-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty