Healthcare Provider Details

I. General information

NPI: 1255591517
Provider Name (Legal Business Name): GARY LYNN DENNINGTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 EAST LINCOLN ROAD
IDABEL OK
74745-7349
US

IV. Provider business mailing address

1510 EAST LINCOLN ROAD
IDABEL OK
74745-7349
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-3051
  • Fax: 580-286-6960
Mailing address:
  • Phone: 580-286-3051
  • Fax: 580-286-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4822
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4822
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4822
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: