Provider Demographics
NPI:1730671371
Name:DOMIAN, ALLYSON P (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALLYSON
Middle Name:P
Last Name:DOMIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2648
Mailing Address - Country:US
Mailing Address - Phone:918-743-2928
Mailing Address - Fax:918-743-2295
Practice Address - Street 1:1321 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-2648
Practice Address - Country:US
Practice Address - Phone:918-743-2928
Practice Address - Fax:918-743-2295
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730671371OtherNPI