1750660700 NPI number — HENYRETTA DENTAL CENTER 2, 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 1750660700 NPI number — HENYRETTA DENTAL CENTER 2, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENYRETTA DENTAL CENTER 2, 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:
1750660700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 S 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENRYETTA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74437-5009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-652-2555
Provider Business Mailing Address Fax Number:
918-652-2556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 S 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENRYETTA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74437-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-652-2555
Provider Business Practice Location Address Fax Number:
918-652-2556
Provider Enumeration Date:
08/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
98186522555

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  5868 , 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)

  • Identifier: 200085770A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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