Healthcare Provider Details

I. General information

NPI: 1598980583
Provider Name (Legal Business Name): CORWIN FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E 7TH AVE
BRISTOW OK
74010-2503
US

IV. Provider business mailing address

221 E 7TH AVE
BRISTOW OK
74010-2503
US

V. Phone/Fax

Practice location:
  • Phone: 918-367-3290
  • Fax:
Mailing address:
  • Phone: 918-367-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5011
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4993
License Number StateOK

VIII. Authorized Official

Name: JAMES OWEN CORWIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 918-367-3290