Provider Demographics
NPI:1699951053
Name:OKLAHOMA WISDOM TEETH CENTER
Entity type:Organization
Organization Name:OKLAHOMA WISDOM TEETH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:918-491-9996
Mailing Address - Street 1:7316 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6016
Mailing Address - Country:US
Mailing Address - Phone:918-491-9996
Mailing Address - Fax:918-491-6999
Practice Address - Street 1:7316 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6016
Practice Address - Country:US
Practice Address - Phone:918-491-9996
Practice Address - Fax:918-491-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty