Provider Demographics
NPI:1851566731
Name:JERRY L. THORMAN, DDS, INC.
Entity Type:Organization
Organization Name:JERRY L. THORMAN, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:THORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-756-4933
Mailing Address - Street 1:500 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5503
Mailing Address - Country:US
Mailing Address - Phone:918-756-4933
Mailing Address - Fax:918-756-7781
Practice Address - Street 1:500 E 8TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5503
Practice Address - Country:US
Practice Address - Phone:918-756-4933
Practice Address - Fax:918-756-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3202261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100122240AMedicaid