Healthcare Provider Details

I. General information

NPI: 1851531826
Provider Name (Legal Business Name): BRISTOW DENTAL DESIGNS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N MAIN ST
BRISTOW OK
74010-2429
US

IV. Provider business mailing address

PO BOX 867
BRISTOW OK
74010-0867
US

V. Phone/Fax

Practice location:
  • Phone: 918-367-3361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberOK5948
License Number StateOK

VIII. Authorized Official

Name: DR. AMANDA HENDRICKSON
Title or Position: DENTIST
Credential:
Phone: 918-367-3361