Provider Demographics
NPI:1396458857
Name:RONISHA DURHAM DDS PLLC
Entity type:Organization
Organization Name:RONISHA DURHAM DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-569-2604
Mailing Address - Street 1:2701 N 23RD ST APT 2403
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2171
Mailing Address - Country:US
Mailing Address - Phone:405-569-2604
Mailing Address - Fax:
Practice Address - Street 1:15260 LLEYTONS CT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-7301
Practice Address - Country:US
Practice Address - Phone:405-492-7862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200432880AMedicaid