Provider Demographics
NPI:1982282802
Name:BUCCAL UP DENTAL TULSA PLLC
Entity Type:Organization
Organization Name:BUCCAL UP DENTAL TULSA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-960-3070
Mailing Address - Street 1:300 RIVERWALK TER STE 220
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5617
Mailing Address - Country:US
Mailing Address - Phone:918-960-3070
Mailing Address - Fax:
Practice Address - Street 1:4606 E 67TH ST STE 312
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-4950
Practice Address - Country:US
Practice Address - Phone:918-494-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty