1780001636 NPI number — DENTAL DEPOT OF BROKEN ARROW, PLLC

Table of content: (NPI 1780001636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780001636 NPI number — DENTAL DEPOT OF BROKEN ARROW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL DEPOT OF BROKEN ARROW, 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:
1780001636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2828 NW 30TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-7404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-945-8941
Provider Business Mailing Address Fax Number:
405-945-8959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 W KENOSHA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74012-8944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-945-8941
Provider Business Practice Location Address Fax Number:
405-945-8959
Provider Enumeration Date:
03/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ASHMORE
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
OWNER / PRESIDENT
Authorized Official Telephone Number:
405-949-0123

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3723 , 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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