MEDICARE: SIGNATURE DENTAL, INC

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	261QD0000X	Dental Clinic/Center	5877	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	:	1740455245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIGNATURE DENTAL, INC

Provider Business Mailing Address
First Line	:	2620 NW EXPRESSWAY
Second Line	:	SUITE E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-7281
Country	:	US
Telephone Number	:	405-943-0123
Fax Number	:	405-945-0234

Provider Business Practice Location Address
First Line	:	2620 NW EXPRESSWAY
Second Line	:	SUITE E
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-7281
Country	:	US
Telephone Number	:	405-943-0123
Fax Number	:	405-945-0234

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KESA MCCONNELL-POORE
Credential	:	D.D.S.
Telephone Number	:	405-943-0123

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	04/17/2009

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Directions to “SIGNATURE DENTAL, INC ” Practice Location

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