Healthcare Provider Details

I. General information

NPI: 1285202580
Provider Name (Legal Business Name): SAPULPA KIDS DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 E LINCOLN AVE
SAPULPA OK
74066-4505
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 918-224-7000
  • Fax:
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-310-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CREED CARDON
Title or Position: OWNER
Credential:
Phone: 918-998-0996