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General NPI Number Information
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NPI Number | 1548526106
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Entity Type | Organization
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Legal Business Name | MUSKOGEE DENTAL GROUP, INC.
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Dates
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Enumeration Date | 04/09/2012
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Last Update Date | 04/09/2012
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Provider Practice Location Address
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Address Line | 2909 AZALEA PARK DR
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City | MUSKOGEE
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State | OK
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Zip | 74401-2283
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Country | US
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Telephone | 918-682-0544
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Fax | 918-682-1004
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Provider Business Mailing Address
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Address Line | 2909 AZALEA PARK DR
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City | MUSKOGEE
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State | OK
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Zip | 74401-2283
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Country | US
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Telephone | 918-682-0544
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Fax | 918-682-1004
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Authorized Official
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Title or Position | OWENER
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Name | DR. TERRY D. GRUBBS
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Credential | D.D.S.
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Telephone | 918-682-0544
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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 | 3843
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License Number State | OK
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