Healthcare Provider Details

I. General information

NPI: 1972679074
Provider Name (Legal Business Name): COALGATE DENTAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W CLAY
COALGATE OK
74538
US

IV. Provider business mailing address

405 W CLAY
COALGATE OK
74538
US

V. Phone/Fax

Practice location:
  • Phone: 580-927-2331
  • Fax: 580-927-2332
Mailing address:
  • Phone: 580-927-2331
  • Fax: 580-927-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5382
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID A KING
Title or Position: DENTIST PRESIDENT
Credential: DDS
Phone: 580-927-2331