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General NPI Number Information
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NPI Number | 1558744995
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY
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Dates
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Enumeration Date | 07/02/2015
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Last Update Date | 07/02/2015
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Provider Practice Location Address
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Address Line | 1618 N 5TH ST STE 2
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City | PONCA CITY
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State | OK
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Zip | 74601-2764
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Country | US
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Telephone | 580-762-5624
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Fax |
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Provider Business Mailing Address
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Address Line | 1618 N 5TH ST STE 2
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City | PONCA CITY
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State | OK
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Zip | 74601-2764
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Country | US
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Telephone | 580-762-5624
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | QUINT WHITEFIELD
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Credential | DDS
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Telephone | 580-762-5624
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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 | 7645
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License Number State | OK
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