Healthcare Provider Details

I. General information

NPI: 1114449394
Provider Name (Legal Business Name): SHATTUCK DENTISTRY & BRACES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 S MAIN ST
SHATTUCK OK
73858-9223
US

IV. Provider business mailing address

1523 S. MAIN
SHATTUCK OK
73858
US

V. Phone/Fax

Practice location:
  • Phone: 580-938-2566
  • Fax: 580-938-2567
Mailing address:
  • Phone: 580-938-2566
  • Fax: 580-938-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN JAMES BOWMAN
Title or Position: MANAGER
Credential: DDS
Phone: 405-326-8004