Provider Demographics
NPI:1861484776
Name:LAVALLEY, JOSEPH OMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:OMER
Last Name:LAVALLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E HWY
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848
Mailing Address - Country:US
Mailing Address - Phone:405-379-2700
Mailing Address - Fax:405-379-2703
Practice Address - Street 1:300 E HWY
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848
Practice Address - Country:US
Practice Address - Phone:405-379-2700
Practice Address - Fax:405-379-2703
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2007-07-09
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
OK5172122300000X
TX19688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist