Provider Demographics
NPI:1104054170
Name:WARLICK, KATIE LARUE (DDS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LARUE
Last Name:WARLICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-4101
Mailing Address - Country:US
Mailing Address - Phone:918-279-8880
Mailing Address - Fax:
Practice Address - Street 1:129 S BROADWAY
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-4101
Practice Address - Country:US
Practice Address - Phone:918-279-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK080116301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200267680AMedicaid