1992849996 NPI number — KINGFISHER DENTAL PLLC

Table of content: (NPI 1992849996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992849996 NPI number — KINGFISHER DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGFISHER 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:
1992849996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9060 HARMONY DR
Provider Second Line Business Mailing Address:
STE E
Provider Business Mailing Address City Name:
MIDWEST CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-594-8844
Provider Business Mailing Address Fax Number:
405-485-8043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 STARLITE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGFISHER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-375-5855
Provider Business Practice Location Address Fax Number:
405-358-2946
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-375-5855

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3767 , 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: 200208490A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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