Basic Information
| Provider Information | |||||||||
| NPI: | 1053875690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERO DENTAL OF OKLAHOMA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7715 E 91ST ST STE A | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741336060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188727009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7196490305 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.