MEDICARE: STORTS FAMILY DENTISTRY, JESSE D. STORTS, JR. PC

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	4633	OK

General Provider Information

NPI Number	:	1427344738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STORTS FAMILY DENTISTRY, JESSE D. STORTS, JR. PC

Provider Business Mailing Address
First Line	:	1220 MERRICK DR.
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401
Country	:	US
Telephone Number	:	580-223-6720
Fax Number	:	580-223-6724

Provider Business Practice Location Address
First Line	:	1220 MERRICK DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1824
Country	:	US
Telephone Number	:	580-223-6720
Fax Number	:	580-223-6724

Authorized Official
Title or Position	:	DENTISTS
Name	:	MR. JESSE D STORTS JR.
Credential	:	D.D.S.
Telephone Number	:	580-223-6720

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

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