Basic Information
Provider Information | |||||||||
NPI: | 1164798757 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERO DENTAL OF TULSA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTURE DENTAL OF TULSA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 N NEVADA AVE | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809031708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195761850 | ||||||||
FaxNumber: | 7195761929 | ||||||||
Practice Location | |||||||||
Address1: | 4955 S PEORIA AVE | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741050000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195761850 | ||||||||
FaxNumber: | 7195761929 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2012 | ||||||||
LastUpdateDate: | 07/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERRYHILL | ||||||||
AuthorizedOfficialFirstName: | RENEE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7195761850 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.