Provider Demographics
NPI:1831418201
Name:ROOT, TERRY ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:ROBERT
Last Name:ROOT
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 1:58 ST ANDREWS CIR
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1107
Mailing Address - Country:US
Mailing Address - Phone:918-252-0878
Mailing Address - Fax:
Practice Address - Street 1:58 ST ANDREWS CIR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-1107
Practice Address - Country:US
Practice Address - Phone:918-252-0878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist