=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235514183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSE ROCK FAMILY DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1526 W 8TH AVE
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-4372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-377-7323
-----------------------------------------------------
Fax | 405-372-1576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1526 W 8TH AVE
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-4372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-377-7323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | DR. SARA BASSETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 405-377-7323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------