=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508679598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL DEPOT ORTHODONTICS BROKEN ARROW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2025
-----------------------------------------------------
Last Update Date | 01/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 W KENOSHA ST STE B
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-8944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 539-476-9588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 NW 30TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-7404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-945-8941
-----------------------------------------------------
Fax | 405-945-8959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PROVIDER RELATIONS
-----------------------------------------------------
Name | GAYLON ZISSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-945-8941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------