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General NPI Number Information
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NPI Number | 1043253263
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Entity Type | Organization
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Legal Business Name | DDSI SOUTH AEC LLC
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 02/10/2021
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Provider Practice Location Address
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Address Line | 4201 SOUTH WESTERN STE. 4000
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City | OKLAHOMA CITY
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State | OK
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Zip | 73109-3410
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Country | US
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Telephone | 405-632-4000
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Fax | 405-632-4073
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Provider Business Mailing Address
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Address Line | 4201 S WESTERN AVE
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City | OKLAHOMA CITY
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State | OK
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Zip | 73109-3410
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DIANA J MOCK
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Credential |
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Telephone | 405-767-6630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 0075
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License Number State | OK
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