Provider Demographics
NPI:1023253226
Name:CRANIOFACIAL PAIN TMJ & SLEEP OF OK
Entity type:Organization
Organization Name:CRANIOFACIAL PAIN TMJ & SLEEP OF OK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-321-8030
Mailing Address - Street 1:448 36TH AVE NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4746
Mailing Address - Country:US
Mailing Address - Phone:405-321-8030
Mailing Address - Fax:405-321-2108
Practice Address - Street 1:448 36TH AVE NW
Practice Address - Street 2:SUITE 103
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4746
Practice Address - Country:US
Practice Address - Phone:405-321-8030
Practice Address - Fax:405-321-2108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRANIOFACIAL PAIN, TMJ & SLEEP OF OK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-03
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6411280001Medicare NSC
OKU12320Medicare UPIN