Provider Demographics
NPI:1336400134
Name:DURHAM, RONISHA GALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONISHA
Middle Name:GALE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:RONISHA
Other - Middle Name:GALE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1420 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-949-4450
Mailing Address - Fax:918-794-7728
Practice Address - Street 1:1420 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-949-4450
Practice Address - Fax:918-794-7728
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64201223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1336400134Medicaid