Healthcare Provider Details

I. General information

NPI: 1174565790
Provider Name (Legal Business Name): L KENT SHACKLETT D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 E 45TH ST
TULSA OK
74135-2901
US

IV. Provider business mailing address

3305 E 45TH ST
TULSA OK
74135-2901
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-2315
  • Fax: 918-743-2243
Mailing address:
  • Phone: 918-743-2315
  • Fax: 918-743-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2 2987 & 55 ORTHO
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: