Healthcare Provider Details

I. General information

NPI: 1881441699
Provider Name (Legal Business Name): DENTAL DEPOT OF OWASSO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8722 N GARNETT ROAD
OWASSO OK
74055
US

IV. Provider business mailing address

2828 NW 30TH ST
OKLAHOMA CITY OK
73112-7404
US

V. Phone/Fax

Practice location:
  • Phone: 918-973-7123
  • Fax: 539-208-3596
Mailing address:
  • Phone: 918-973-7123
  • Fax: 539-208-3596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GAYLON ZISSA
Title or Position: DIRECTOR OF PROVIDER RELATIONS
Credential:
Phone: 405-945-8941