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General NPI Number Information
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NPI Number | 1235141029
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Entity Type | Organization
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Legal Business Name | EAGLE DENTAL CORP INC
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6520 EAST RENO
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City | MIDWEST CITY
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State | OK
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Zip | 73110-2109
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Country | US
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Telephone | 405-732-6821
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Fax | 405-732-7970
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Provider Business Mailing Address
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Address Line | 6520 EAST RENO
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City | MIDWEST CITY
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State | OK
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Zip | 73110-2109
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Country | US
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Telephone | 405-732-6821
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Fax | 405-732-7970
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Authorized Official
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Title or Position | CEO VICE PRESIDENT
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Name | DR. MARY E MARTIN
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Credential | DDS
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Telephone | 405-732-6821
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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 | 4609
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4594
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License Number State | OK
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