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General NPI Number Information
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NPI Number | 1548565070
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Entity Type | Organization
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Legal Business Name | PAWNEE DENTAL CLINIC
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Dates
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Enumeration Date | 01/13/2011
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Last Update Date | 01/13/2011
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Provider Practice Location Address
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Address Line | 622 7TH ST
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City | PAWNEE
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State | OK
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Zip | 74058-2541
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Country | US
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Telephone | 918-762-3501
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Fax | 918-762-2600
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Provider Business Mailing Address
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Address Line | 622 7TH ST
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City | PAWNEE
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State | OK
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Zip | 74058-2541
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Country | US
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Telephone | 918-762-3501
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Fax | 918-762-2600
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Authorized Official
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Title or Position | DENTIST
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Name | DR. GARY STARK HENDERSON
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Credential | D.D.S.
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Telephone | 918-762-3501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3796
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License Number State | OK
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