Healthcare Provider Details

I. General information

NPI: 1093332959
Provider Name (Legal Business Name): GRAHAM THOMAS SHADWICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE RM 241
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

123 NE 2ND ST APT 253
OKLAHOMA CITY OK
73104-2260
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5222
  • Fax:
Mailing address:
  • Phone: 913-744-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7323
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: