Healthcare Provider Details

I. General information

NPI: 1043253263
Provider Name (Legal Business Name): DDSI SOUTH AEC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SOUTH WESTERN STE. 4000
OKLAHOMA CITY OK
73109-3410
US

IV. Provider business mailing address

4201 S WESTERN AVE
OKLAHOMA CITY OK
73109-3410
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-4000
  • Fax: 405-632-4073
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0075
License Number StateOK

VIII. Authorized Official

Name: DIANA J MOCK
Title or Position: DIRECTOR
Credential:
Phone: 405-767-6630