Basic Information
| Provider Information | |||||||||
| NPI: | 1629227897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LITTLE AXE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15951 LITTLE AXE DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Practice Location | |||||||||
| Address1: | 15951 LITTLE AXE DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4054470300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MAL, FACHE, CMPE, CH | ||||||||
| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100699860B | 05 | OK | MEDICAID | 100699860N | 05 | OK | MEDICAID | 100699860A | 05 | OK | MEDICAID |