1629325261 NPI number — MODERN DENTAL PROFESSIONALS - OKLAHOMA, PC

Table of content: (NPI 1629325261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629325261 NPI number — MODERN DENTAL PROFESSIONALS - OKLAHOMA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESSIONALS - OKLAHOMA, PC
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:
1629325261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 N MAY AVE
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:
73112-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-996-1030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 WINDCREST DR
Provider Second Line Business Practice Location Address:
STE. #100
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75024-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-212-8135
Provider Business Practice Location Address Fax Number:
972-767-4885
Provider Enumeration Date:
08/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PEEK
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PC OWNER/DENTIST
Authorized Official Telephone Number:
972-212-8135

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)





Copyright © 2007-2025 www.npivalidator.com