=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184282329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRICK LLOYD WASHINGTON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 12TH AVE NW
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-5722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-3411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4608 ROCK CREEK RD
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-6596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-504-4217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7167
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------