Healthcare Provider Details

I. General information

NPI: 1366568438
Provider Name (Legal Business Name): SOUTHWEST PEDIATRIC DENTAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 SW 89TH ST SUITE A
OKLAHOMA CITY OK
73139-9300
US

IV. Provider business mailing address

809 SW 89TH ST SUITE A
OKLAHOMA CITY OK
73139-9300
US

V. Phone/Fax

Practice location:
  • Phone: 405-616-7336
  • Fax: 405-616-5756
Mailing address:
  • Phone: 405-616-7336
  • Fax: 405-616-5756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4636
License Number StateOK

VIII. Authorized Official

Name: DR. THERESA M. WHITE
Title or Position: MANAGER
Credential: DDS
Phone: 405-616-7336