Healthcare Provider Details

I. General information

NPI: 1265691695
Provider Name (Legal Business Name): JERRY D MCCAN DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 CEDAR SPRINGS DRIVE
TUTTLE OK
73089-7929
US

IV. Provider business mailing address

7 CEDAR SPRINGS DRIVE
TUTTLE OK
73089-7929
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-2303
  • Fax: 405-381-2304
Mailing address:
  • Phone: 405-381-2303
  • Fax: 405-381-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4124
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100106100B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: DR. JERRY D MCCAN
Title or Position: OWNER
Credential: DDS
Phone: 405-381-2303