=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366337966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDEAL DENTAL NORTHWEST OKLAHOMA CITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2025
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3629 NW 178TH STREET STE D
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-361-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12750 MERIT DR STE 1100
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75251-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP REVENUE CYCLE
-----------------------------------------------------
Name | CAROL CANAVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-331-8079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------