Provider Demographics
NPI:1912337643
Name:DODD, LATANYA
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:DODD
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 1:1540 E 68TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-4119
Mailing Address - Country:US
Mailing Address - Phone:317-457-3933
Mailing Address - Fax:
Practice Address - Street 1:1540 E 68TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:317-457-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0850X261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5400-21-9970OtherOKLAHOMA DRIVERS LISCENSE