Healthcare Provider Details

I. General information

NPI: 1760536866
Provider Name (Legal Business Name): DAVID W PEDICORD DDS MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 E 67TH STREET SUITE 208
TULSA OK
74136
US

IV. Provider business mailing address

4606 E 67TH STREET STE 208
TULSA OK
74136
US

V. Phone/Fax

Practice location:
  • Phone: 918-491-5888
  • Fax: 918-491-5883
Mailing address:
  • Phone: 918-491-5888
  • Fax: 918-491-5883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberOK3706
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: