Provider Demographics
NPI:1124131172
Name:FAMILY DENTISTRY OF BROKEN ARROW PC
Entity type:Organization
Organization Name:FAMILY DENTISTRY OF BROKEN ARROW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:918-455-3777
Mailing Address - Street 1:2001 S ELM PL
Mailing Address - Street 2:SUITE E
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-455-3777
Mailing Address - Fax:918-451-6316
Practice Address - Street 1:2001 S ELM PL
Practice Address - Street 2:SUITE E
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-455-3777
Practice Address - Fax:918-451-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty