Healthcare Provider Details

I. General information

NPI: 1104667732
Provider Name (Legal Business Name): MALLORY SHOEMAKE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 N MAIN ST
MIAMI OK
74354-2748
US

IV. Provider business mailing address

1816 N MAIN ST
MIAMI OK
74354-2748
US

V. Phone/Fax

Practice location:
  • Phone: 918-542-3337
  • Fax:
Mailing address:
  • Phone: 918-542-3337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7859
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: