Healthcare Provider Details

I. General information

NPI: 1245660968
Provider Name (Legal Business Name): OKC SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SW 107TH ST
OKLAHOMA CITY OK
73170
US

IV. Provider business mailing address

930 SW 107TH ST
OKLAHOMA CITY OK
73170
US

V. Phone/Fax

Practice location:
  • Phone: 405-634-7303
  • Fax:
Mailing address:
  • Phone: 405-634-7303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STERLING STALDER
Title or Position: OWNER
Credential: DDS
Phone: 405-728-1278