Healthcare Provider Details

I. General information

NPI: 1992536478
Provider Name (Legal Business Name): FAIRFAX DENTAL OFFICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 11/26/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 N 2ND ST
FAIRFAX OK
74637
US

IV. Provider business mailing address

158 N 2ND ST
FAIRFAX OK
74637
US

V. Phone/Fax

Practice location:
  • Phone: 918-642-3400
  • Fax:
Mailing address:
  • Phone: 918-642-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ZANE GREY MILLS
Title or Position: DENTIST
Credential: DDS
Phone: 918-642-3400