1861597866 NPI number — MYRNA DOMONEY DDS, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861597866 NPI number — MYRNA DOMONEY DDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYRNA DOMONEY DDS, PLLC
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:
6
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:
1861597866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 S EUCALYPTUS AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-250-0624
Provider Business Mailing Address Fax Number:
918-250-9437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1621 S EUCALYPTUS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-250-0624
Provider Business Practice Location Address Fax Number:
918-250-9437
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOMONEY
Authorized Official First Name:
MYRNA
Authorized Official Middle Name:
BYERS
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
918-250-0624

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5042 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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