MEDICARE: SUNRISE DENTISTRY OF OKC PLLC

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1184514473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE DENTISTRY OF OKC PLLC

Provider Business Mailing Address
First Line	:	400 RIVERWALK TER STE 250
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-5619
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:	918-235-9079

Provider Business Practice Location Address
First Line	:	4440 NW EXPRESSWAY STE A
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1533
Country	:	US
Telephone Number	:	405-456-0610
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	CREED CARDON
Credential	:
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	07/08/2025
Last Update Date	:	09/16/2025

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