Provider Demographics
NPI:1912453085
Name:LE, SALLY AI THIEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:AI THIEN
Last Name:LE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 S MIMOSA AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1143
Mailing Address - Country:US
Mailing Address - Phone:918-853-1128
Mailing Address - Fax:
Practice Address - Street 1:6416 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-4819
Practice Address - Country:US
Practice Address - Phone:918-940-3244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist