Provider Demographics
NPI:1013401066
Name:DEREK R COHLMIA DDS PLLC
Entity Type:Organization
Organization Name:DEREK R COHLMIA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:COHLMIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-2886
Mailing Address - Street 1:4301 NW 63RD ST STE 303
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1504
Mailing Address - Country:US
Mailing Address - Phone:405-848-2886
Mailing Address - Fax:405-848-6664
Practice Address - Street 1:4301 NW 63RD ST STE 303
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1504
Practice Address - Country:US
Practice Address - Phone:405-848-2886
Practice Address - Fax:405-848-6664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6933261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1184154023OtherDENTAL
OK=========OtherDENTAL
OK1184154023OtherDENTAL