Provider Demographics
NPI:1902504038
Name:BELLUSA, SARA MAHMOUD
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:MAHMOUD
Last Name:BELLUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-8013
Mailing Address - Country:US
Mailing Address - Phone:405-415-1420
Mailing Address - Fax:
Practice Address - Street 1:2123 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-8013
Practice Address - Country:US
Practice Address - Phone:405-415-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK78831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice