Healthcare Provider Details

I. General information

NPI: 1164720520
Provider Name (Legal Business Name): JAMES PECK DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 N WESTERN AVE STE 106
EDMOND OK
73012
US

IV. Provider business mailing address

18001 N WESTERN AVE STE 106
EDMOND OK
73012
US

V. Phone/Fax

Practice location:
  • Phone: 405-562-9550
  • Fax:
Mailing address:
  • Phone: 405-562-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6111
License Number StateOK

VIII. Authorized Official

Name: DR. JAMES CALVIN PECK JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 405-562-9550