Healthcare Provider Details

I. General information

NPI: 1598126799
Provider Name (Legal Business Name): OKC DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 SW 59TH ST. STE 105
OKLAHOMA CITY OK
73109
US

IV. Provider business mailing address

400 RIVERWALK TERRACE STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 918-895-6568
  • Fax:
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: RENEE MCBAY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 918-998-0996