Healthcare Provider Details

I. General information

NPI: 1235823162
Provider Name (Legal Business Name): SLADE TAYLOR SHUCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 S MILLER LN STE B
CATOOSA OK
74015-1539
US

IV. Provider business mailing address

8601 S MINGO RD APT 7301
TULSA OK
74133-4648
US

V. Phone/Fax

Practice location:
  • Phone: 918-266-6473
  • Fax:
Mailing address:
  • Phone: 620-453-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7764
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: