1215470497 NPI number — OKC 89TH DENTAL, PLLC

Table of content: (NPI 1215470497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215470497 NPI number — OKC 89TH DENTAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKC 89TH 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:
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:
1215470497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 RIVERWALK TER STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENKS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74037-5619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-998-0996
Provider Business Mailing Address Fax Number:
918-235-9079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7801 S WESTERN AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73139-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-691-3399
Provider Business Practice Location Address Fax Number:
405-256-1191
Provider Enumeration Date:
11/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CARDON
Authorized Official First Name:
CREED
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-998-0996

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200679550A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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