NPIMap

Organization Active NPI

Eastern Oklahoma Oral and Maxillofacial Surgeons

  • Oral and Maxillofacial Surgery (Dentist)
  • Broken Arrow, OK
National Provider Identifier
1487074704
Registry record updated Mar 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
Legal business name
EASTERN OKLAHOMA ORAL AND MAXILLOFACIAL SURGEONS
Practice address
4716 W Urbana St
Broken Arrow, OK 74012-5997
Phone
(918) 449-5800
Fax
(918) 455-8958
NPI assigned
Apr 25, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Angie Roe
Title
Credentialing and Contracting
Phone
(888) 247-1869

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X Primary

Addresses

Primary practice location

4716 W Urbana St
Broken Arrow, OK 74012-5997

Mailing address

4716 W Urbana St
Broken Arrow, OK 74012-5997
Phone (918) 449-5800

Other practice location 1

12802 E 101st Pl N
Owasso, OK 74055-4662
Phone (918) 274-0944

Other identifiers 2

IdentifierTypeStateIssuer
200537790AMedicaidOK
200537790BMedicaidOK

National Provider Directory

National Provider Directory
Tax ID family
Eastern Oklahoma Oral and Maxillofacial Surgeons2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

12802 E 101st Pl N
Owasso, OK 74055
Phone (918) 274-0944

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1398384000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521244800000",
    "number": "1487074704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4716 W URBANA ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740125997",
            "telephone_number": "918-449-5800",
            "fax_number": "918-455-8958"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4716 W URBANA ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740125997",
            "telephone_number": "918-449-5800",
            "fax_number": "918-455-8958"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "12802 E 101st Pl N",
            "address_purpose": "LOCATION",
            "city": "Owasso",
            "state": "OK",
            "postal_code": "740554662",
            "country_code": "US",
            "telephone_number": "918-274-0944",
            "fax_number": "918-274-1366",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EASTERN OKLAHOMA ORAL AND MAXILLOFACIAL SURGEONS",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-25",
        "last_updated": "2018-03-17",
        "status": "A",
        "authorized_official_last_name": "ROE",
        "authorized_official_first_name": "ANGIE",
        "authorized_official_title_or_position": "CREDENTIALING AND CONTRACTING",
        "authorized_official_telephone_number": "888-247-1869",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200537790A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200537790B",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Broken Arrow, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.