Provider Demographics
NPI:1134898216
Name:SOPE, AMIT BALASAHEB
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:BALASAHEB
Last Name:SOPE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 HARDY SPRINGS CIR APT A
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7375
Mailing Address - Country:US
Mailing Address - Phone:682-307-9203
Mailing Address - Fax:
Practice Address - Street 1:611 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7277
Practice Address - Country:US
Practice Address - Phone:918-715-3266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist