Provider Demographics
NPI:1932879699
Name:OKLAHOMA AESTHETIC RECONSTRUCTIVE SURGERY LLC
Entity Type:Organization
Organization Name:OKLAHOMA AESTHETIC RECONSTRUCTIVE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-735-9700
Mailing Address - Street 1:2708 W COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-4219
Mailing Address - Country:US
Mailing Address - Phone:405-246-0391
Mailing Address - Fax:405-246-0392
Practice Address - Street 1:13820 WIRELESS WAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-2501
Practice Address - Country:US
Practice Address - Phone:405-246-0391
Practice Address - Fax:405-246-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty