Healthcare Provider Details

I. General information

NPI: 1003236969
Provider Name (Legal Business Name): OKC DENTAL HEALTH ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 E. HWY 152
MUSTANG OK
73064
US

IV. Provider business mailing address

1041 E. HWY 152
MUSTANG OK
73064
US

V. Phone/Fax

Practice location:
  • Phone: 405-256-0037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRETT DETERS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-8921