Provider Demographics
NPI:1295254068
Name:SIH OKLAHOMA PC
Entity type:Organization
Organization Name:SIH OKLAHOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:TULL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:913-254-4065
Mailing Address - Street 1:4400 SHAWNEE MISSION PKWY STE 208
Mailing Address - Street 2:
Mailing Address - City:FAIRWAY
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2518
Mailing Address - Country:US
Mailing Address - Phone:800-492-4664
Mailing Address - Fax:913-747-1001
Practice Address - Street 1:1325 N WALKER AVE 547
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-6405
Practice Address - Country:US
Practice Address - Phone:800-492-4664
Practice Address - Fax:913-747-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QD0000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental