MEDICARE: TRISTANNE SPOTTSWOOD, DMD, LLC

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	122300000X	Dentist	5910	OK

General Provider Information

NPI Number	:	1679960587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRISTANNE SPOTTSWOOD, DMD, LLC

Provider Business Mailing Address
First Line	:	1512 SW 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6307
Country	:	US
Telephone Number	:	405-691-3399
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 SW 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6307
Country	:	US
Telephone Number	:	405-691-3399
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	TRISTANNE SPOTTSWOOD
Credential	:	DMD
Telephone Number	:	405-691-3399

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	04/17/2015

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