1134279102 NPI number — TEJ D. LAD DDS INC PC

Table of content: (NPI 1134279102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134279102 NPI number — TEJ D. LAD DDS INC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEJ D. LAD DDS INC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134279102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENKS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74037-3518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-369-6118
Provider Business Mailing Address Fax Number:
918-369-6121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENKS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74037-3518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-369-6118
Provider Business Practice Location Address Fax Number:
918-369-6121
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAD
Authorized Official First Name:
TEJ
Authorized Official Middle Name:
DATTATRAYA
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
918-369-6118

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5667 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200095240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".