Provider Demographics
NPI:1265735724
Name:MICHAEL J. GLIDDON DBA LIVE OAK ORAL SURGERY
Entity type:Organization
Organization Name:MICHAEL J. GLIDDON DBA LIVE OAK ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING REP
Authorized Official - Prefix:
Authorized Official - First Name:VERA ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:3000 UNITED FOUNDERS BLVD
Mailing Address - Street 2:SUITE 237
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3958
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:1415 NW 33RD ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3806
Practice Address - Country:US
Practice Address - Phone:580-699-3131
Practice Address - Fax:580-699-3151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty