Provider Demographics
NPI:1255773339
Name:HIGGINSON, JAKE RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:RYAN
Last Name:HIGGINSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6217 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1605
Mailing Address - Country:US
Mailing Address - Phone:405-606-7123
Mailing Address - Fax:
Practice Address - Street 1:6217 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1605
Practice Address - Country:US
Practice Address - Phone:405-606-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist