Provider Demographics
NPI:1245725589
Name:ISRAELSEN, LOREN PAUL (DDS)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:PAUL
Last Name:ISRAELSEN
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 1:2616 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2838
Mailing Address - Country:US
Mailing Address - Phone:405-275-7730
Mailing Address - Fax:
Practice Address - Street 1:2616 N PARK AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2838
Practice Address - Country:US
Practice Address - Phone:405-275-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice