Healthcare Provider Details

I. General information

NPI: 1750688248
Provider Name (Legal Business Name): CARRIE DS FAMILY DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RIVERWALK TERRACE SUITE 200
JENKS OK
74037-5627
US

IV. Provider business mailing address

400 RIVERWALK TERRACE SUITE 200
JENKS OK
74037-5627
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-7654
  • Fax: 918-518-5760
Mailing address:
  • Phone: 918-392-7654
  • Fax: 918-518-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5239
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CARRIE D SESSOM
Title or Position: OWNER
Credential: D.D.S.
Phone: 918-392-7654