1659157691 NPI number — DENTAL DEPOT ORTHODONTICS DEL CITY, PLLC

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 1659157691 NPI number — DENTAL DEPOT ORTHODONTICS DEL CITY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL DEPOT ORTHODONTICS DEL CITY, 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:
1659157691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
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:
405-900-8939
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5004 SE 29TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEL CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73115-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-900-8939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ZISSA
Authorized Official First Name:
GAYLON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROVIDER RELATIONS
Authorized Official Telephone Number:
405-945-8941

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)





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