Healthcare Provider Details

I. General information

NPI: 1629211594
Provider Name (Legal Business Name): OWASSO PERIODONTICS AND DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 E 88TH PL N
OWASSO OK
74055-4877
US

IV. Provider business mailing address

14600 E 88TH PL N
OWASSO OK
74055-4877
US

V. Phone/Fax

Practice location:
  • Phone: 918-376-2191
  • Fax:
Mailing address:
  • Phone: 918-376-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5727
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID T. STAPLETON
Title or Position: PERIODONTIST
Credential: DDS
Phone: 918-376-2191