Healthcare Provider Details

I. General information

NPI: 1639601859
Provider Name (Legal Business Name): AFFORDABLE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 N 5TH ST STE 4
PONCA CITY OK
74601
US

IV. Provider business mailing address

1618 N 5TH ST STE 4
PONCA CITY OK
74601-2764
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-0112
  • Fax: 580-762-5644
Mailing address:
  • Phone: 580-765-0112
  • Fax: 580-762-5644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5037
License Number StateOK

VIII. Authorized Official

Name: DR. QUINT WHITEFIELD
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 580-762-5624