Healthcare Provider Details

I. General information

NPI: 1396186169
Provider Name (Legal Business Name): DEWEY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 E DON TYLER AVE
DEWEY OK
74029-2315
US

IV. Provider business mailing address

417 E DON TYLER AVE
DEWEY OK
74029-2315
US

V. Phone/Fax

Practice location:
  • Phone: 918-534-3170
  • Fax:
Mailing address:
  • Phone: 918-534-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6473
License Number StateOK

VIII. Authorized Official

Name: DR. NATHAN T BULLEIGH
Title or Position: PRESIDENT/DENTIST
Credential: D.D.S.
Phone: 918-534-3170