Healthcare Provider Details

I. General information

NPI: 1215470497
Provider Name (Legal Business Name): OKC 89TH DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 S WESTERN AVE STE 101
OKLAHOMA CITY OK
73139-2411
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 405-691-3399
  • Fax: 405-256-1191
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-235-9079

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: CREED LOUIS CARDON
Title or Position: OWNER
Credential: DDS
Phone: 918-998-0996