MEDICARE: FIRST IMPRESSIONS DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6061	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053743153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST IMPRESSIONS DENTISTRY

Provider Business Mailing Address
First Line	:	4301 NW 63RD ST
Second Line	:	300
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1549
Country	:	US
Telephone Number	:	405-879-0000
Fax Number	:	405-879-0656

Provider Business Practice Location Address
First Line	:	4301 NW 63RD ST
Second Line	:	300
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1549
Country	:	US
Telephone Number	:	405-879-0000
Fax Number	:	405-879-0656

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATT COLE
Credential	:	DDS
Telephone Number	:	405-879-0000

Provider Enumeration Date	:	07/31/2013
Last Update Date	:	07/31/2013

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Directions to “FIRST IMPRESSIONS DENTISTRY ” Practice Location

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