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General NPI Number Information
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NPI Number | 1104206887
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Entity Type | Organization
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Legal Business Name | PKL ORTHODONTICS, PC
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Dates
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Enumeration Date | 06/08/2015
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Last Update Date | 06/08/2015
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Provider Practice Location Address
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Address Line | 717 S I 35 SERVICE RD STE C
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City | MOORE
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State | OK
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Zip | 73160-3190
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Country | US
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Telephone | 405-378-4774
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Fax |
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Provider Business Mailing Address
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Address Line | 717 S I 35 SERVICE RD STE C
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City | MOORE
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State | OK
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Zip | 73160-3190
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Country | US
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Telephone | 405-378-4774
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Fax |
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Authorized Official
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Title or Position | OWNER/ ORTHODONTIST
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Name | DR. PRISCILLA PICKENS-LARSON
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Credential | DMD
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Telephone | 405-378-4774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 189
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License Number State | OK
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