Provider Demographics
NPI:1649591033
Name:BOUZIDEN, CALLIE D (DDS)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:D
Last Name:BOUZIDEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 S HUDSON PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-2252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8327
Practice Address - Country:US
Practice Address - Phone:918-481-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-20
Last Update Date:2010-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist