Healthcare Provider Details

I. General information

NPI: 1689658700
Provider Name (Legal Business Name): GINA C. BOSTICK D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12716 NE 36TH ST
SPENCER OK
73084-9167
US

IV. Provider business mailing address

PO BOX 30589
MIDWEST CITY OK
73140-3589
US

V. Phone/Fax

Practice location:
  • Phone: 405-769-3301
  • Fax: 405-769-9685
Mailing address:
  • Phone: 405-769-3301
  • Fax: 405-769-9685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4991
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4991
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: