Healthcare Provider Details

I. General information

NPI: 1174607261
Provider Name (Legal Business Name): OKLAHOMA ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 NW GRAND BLVD SUITE A
OKLAHOMA CITY OK
73118
US

IV. Provider business mailing address

1008 NW GRAND BLVD SUITE A
OKLAHOMA CITY OK
73118
US

V. Phone/Fax

Practice location:
  • Phone: 405-843-9330
  • Fax: 405-848-4048
Mailing address:
  • Phone: 405-843-9330
  • Fax: 405-848-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number512734
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number458428
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID BRIAN SHADID
Title or Position: PARTNER
Credential: DDS MSD PC
Phone: 405-843-9330