Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 5650 | OK |
NPI | 1700871779 |
---|---|
Provider Name | Micah J Bevins |
First Address | Tulsa, OK 74133-1940 |
Second Address | Tulsa, OK 74133-1940 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2005 |
Last Update Date | 08/07/2007 |