Healthcare Provider Details

I. General information

NPI: 1538098017
Provider Name (Legal Business Name): JORDAN TYLER BLALOCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W OAK AVE
DUNCAN OK
73533-4537
US

IV. Provider business mailing address

605 W CHOCTAW ST
MARLOW OK
73055-3239
US

V. Phone/Fax

Practice location:
  • Phone: 580-255-6621
  • Fax: 580-252-7345
Mailing address:
  • Phone: 580-467-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8189
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: