Healthcare Provider Details

I. General information

NPI: 1720142060
Provider Name (Legal Business Name): JERRY D SNELL II D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26245 HIGHWAY 82 STE 2
PARK HILL OK
74451-2802
US

IV. Provider business mailing address

26245 HIGHWAY 82 STE 2
PARK HILL OK
74451-2802
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-5140
  • Fax: 918-458-5155
Mailing address:
  • Phone: 918-458-5140
  • Fax: 918-458-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberOK5496
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: