1316458383 NPI number — SOUTH SOONER DENTAL PARTNERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316458383 NPI number — SOUTH SOONER DENTAL PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SOONER DENTAL PARTNERS
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:
1316458383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 SW 4TH ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73160-2494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-384-7071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 SW 4TH ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-384-7071
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PRESCOTT
Authorized Official First Name:
TANNER
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
405-384-7071

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: 1629595046 . This is a "DOCTOR NPI" identifier . This identifiers is of the category "OTHER".




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