Basic Information
Provider Information | |||||||||
NPI: | 1285023911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARZANEH-JOSEPH | ||||||||
FirstName: | MONA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5030 N MAY AVE STE 424 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731126010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4054450023 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3919 N MACARTHUR BLVD | ||||||||
Address2: |   | ||||||||
City: | WARR ACRES | ||||||||
State: | OK | ||||||||
PostalCode: | 731222005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057877827 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2015 | ||||||||
LastUpdateDate: | 06/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6587 | OK | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 020580260A | 05 | OK |   | MEDICAID | 20-0580260-A | 05 | OK |   | MEDICAID |