Healthcare Provider Details

I. General information

NPI: 1912668070
Provider Name (Legal Business Name): TALDG PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2021
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S LEE ST STE A
FORT GIBSON OK
74434-8710
US

IV. Provider business mailing address

801 S LEE ST STE A
FORT GIBSON OK
74434-8710
US

V. Phone/Fax

Practice location:
  • Phone: 918-478-4433
  • Fax:
Mailing address:
  • Phone: 918-478-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDI WILLIAMS
Title or Position: VP OF GROWTH
Credential:
Phone: 405-250-2255