Provider Demographics
NPI:1730810979
Name:RENKEN, TEVIN
Entity type:Individual
Prefix:
First Name:TEVIN
Middle Name:
Last Name:RENKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4535
Mailing Address - Country:US
Mailing Address - Phone:580-442-5925
Mailing Address - Fax:
Practice Address - Street 1:605 RANDOLPH ROAD
Practice Address - Street 2:USA DENTAL HEALTH ACTIVITY, COWAN DC
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-5645
Practice Address - Country:US
Practice Address - Phone:580-442-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist