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General NPI Number Information
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NPI Number | 1356967079
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Entity Type | Individual
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Provider Name | JACY RAE GLOVER-SECREST DDS
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Gender | Female
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Dates
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Enumeration Date | 06/18/2020
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Last Update Date | 08/25/2025
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Provider Practice Location Address
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Address Line | 700 S EASTERN AVE
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City | MOORE
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State | OK
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Zip | 73160-6199
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Country | US
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Telephone | 405-912-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 9301 STRAKA RD
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City | OKLAHOMA CITY
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State | OK
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Zip | 73165-9630
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Country | US
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Telephone | 405-623-3735
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | T7301
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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 | 7301
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7301
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License Number State | OK
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