Healthcare Provider Details

I. General information

NPI: 1861716243
Provider Name (Legal Business Name): DARRELL R DEDRICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N. MAIN
SEILING OK
73663
US

IV. Provider business mailing address

PO BOX 205 503 N MAIN
SEILING OK
73663-0205
US

V. Phone/Fax

Practice location:
  • Phone: 580-922-3162
  • Fax: 580-922-3162
Mailing address:
  • Phone: 580-922-3162
  • Fax: 580-922-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3050
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: