Provider Demographics
NPI:1932458312
Name:GREEN COUNTRY DENTAL ARTS OF CATOOSA
Entity Type:Organization
Organization Name:GREEN COUNTRY DENTAL ARTS OF CATOOSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SOREN
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:MICHAELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-266-6470
Mailing Address - Street 1:PO BOX 1980
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-1980
Mailing Address - Country:US
Mailing Address - Phone:918-266-6470
Mailing Address - Fax:918-266-6473
Practice Address - Street 1:1755 N. HIGHWAY 66
Practice Address - Street 2:SUITE C
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015
Practice Address - Country:UM
Practice Address - Phone:918-266-6470
Practice Address - Fax:918-266-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty