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General NPI Number Information
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NPI Number | 1053740563
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Entity Type | Organization
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Legal Business Name | COMPLETE COSMETIC CARE DENTISTRY
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Dates
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Enumeration Date | 11/05/2013
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Last Update Date | 11/05/2013
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Provider Practice Location Address
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Address Line | 12136 S YUKON AVE
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City | SAPULPA
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State | OK
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Zip | 74066-6621
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Country | US
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Telephone | 918-216-1000
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Fax | 918-216-1100
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Provider Business Mailing Address
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Address Line | 12136 S YUKON AVE
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City | SAPULPA
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State | OK
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Zip | 74066-6621
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Country | US
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Telephone | 918-216-1000
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Fax | 918-216-1100
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SANDY SALAMANDRA
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Credential |
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Telephone | 918-216-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6032
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License Number State | OK
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