1255413399 NPI number — WT DENTAL PLLC

Table of content: (NPI 1255413399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255413399 NPI number — WT DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WT DENTAL 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:
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:
1255413399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1222 N FLORENCE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
CLAREMORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74017-3147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-341-3933
Provider Business Mailing Address Fax Number:
918-342-8820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1222 N FLORENCE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CLAREMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74017-3147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-341-3933
Provider Business Practice Location Address Fax Number:
918-342-8820
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BATTLE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-341-3933

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3922 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5778 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200066360 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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