Healthcare Provider Details

I. General information

NPI: 1164543385
Provider Name (Legal Business Name): ROBERT DUANE EDSALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N NOBLE AVE
WATONGA OK
73772-3811
US

IV. Provider business mailing address

205 N NOBLE AVE PO BOX 25
WATONGA OK
73772-3811
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-7752
  • Fax: 580-623-5020
Mailing address:
  • Phone: 580-623-7752
  • Fax: 580-623-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4596
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: