Healthcare Provider Details

I. General information

NPI: 1427025501
Provider Name (Legal Business Name): CHARLES ALAN MCQUIGG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W WASHBOURNE ST
JAY OK
74346-4205
US

IV. Provider business mailing address

814 JEFFERSON ST
MIAMI OK
74354-4911
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-8696
  • Fax: 918-253-2871
Mailing address:
  • Phone: 918-542-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4762
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: