Provider Demographics
NPI:1588725485
Name:MICHAEL S BEN INC PC
Entity type:Organization
Organization Name:MICHAEL S BEN INC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:HADLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-642-3400
Mailing Address - Street 1:161 N 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637
Mailing Address - Country:US
Mailing Address - Phone:918-642-3400
Mailing Address - Fax:918-642-3370
Practice Address - Street 1:161 N 2ND STREET
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637
Practice Address - Country:US
Practice Address - Phone:918-642-3400
Practice Address - Fax:918-642-3370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100003750AMedicaid
=========Medicare UPIN
OK100003750AMedicaid