Provider Demographics
NPI:1720228075
Name:OKLAHOMA PERIODONTICS
Entity Type:Organization
Organization Name:OKLAHOMA PERIODONTICS
Other - Org Name:EASTERN OKLAHOMA PERIODOTNICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:918-492-0737
Mailing Address - Street 1:6565 S YALE AVE
Mailing Address - Street 2:1008
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8327
Mailing Address - Country:US
Mailing Address - Phone:918-492-0737
Mailing Address - Fax:918-492-9439
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:1008
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8327
Practice Address - Country:US
Practice Address - Phone:918-492-0737
Practice Address - Fax:918-492-9439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54471223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty