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General NPI Number Information
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NPI Number | 1144576539
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Entity Type | Organization
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Legal Business Name | PROUD DENTAL, PC
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Dates
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Enumeration Date | 08/03/2012
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Last Update Date | 08/03/2012
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Provider Practice Location Address
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Address Line | 324 N 19TH ST SUITE 2
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City | GUTHRIE
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State | OK
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Zip | 73044-2117
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Country | US
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Telephone | 405-282-2530
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Fax | 405-282-2537
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Provider Business Mailing Address
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Address Line | 324 N. 19 ST. SUITE 2
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City | GUTHRIE
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State | OK
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Zip | 73044
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Country | US
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Telephone | 405-282-2530
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Fax | 405-282-2537
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Authorized Official
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Title or Position | DR/OWNER
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Name | NATHAN NICHOLAS PROUD
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Credential | D.D.S.
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Telephone | 405-282-2530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6152
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License Number State | OK
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