Healthcare Provider Details

I. General information

NPI: 1124609771
Provider Name (Legal Business Name): ARDMORE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MERRICK DR
ARDMORE OK
73401-1824
US

IV. Provider business mailing address

2109 COMMERCE ST # 200
DALLAS TX
75201-4305
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-6720
  • Fax:
Mailing address:
  • Phone: 972-248-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM ROBERT JENNINGS JR.
Title or Position: OWNER
Credential: DDS
Phone: 940-206-8956