=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417231887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2011
-----------------------------------------------------
Last Update Date | 10/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8283 SOUTH WALKER SUITE A
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-632-5561
-----------------------------------------------------
Fax | 405-632-6301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8283 S WALKER AVE SUITE A
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73139-9413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-632-5561
-----------------------------------------------------
Fax | 405-632-6301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. BECKI L WALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-632-5561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2758
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------