Healthcare Provider Details

I. General information

NPI: 1780001636
Provider Name (Legal Business Name): DENTAL DEPOT OF BROKEN ARROW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W KENOSHA ST
BROKEN ARROW OK
74012-8944
US

IV. Provider business mailing address

2828 NW 30TH ST
OKLAHOMA CITY OK
73112-7404
US

V. Phone/Fax

Practice location:
  • Phone: 405-945-8941
  • Fax: 405-945-8959
Mailing address:
  • Phone: 405-945-8941
  • Fax: 405-945-8959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3723
License Number StateOK

VIII. Authorized Official

Name: DR. GLENN ALLAN ASHMORE
Title or Position: OWNER / PRESIDENT
Credential: DDS
Phone: 405-949-0123