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General NPI Number Information
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NPI Number | 1831429042
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Entity Type | Organization
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Legal Business Name | DENTAL LODGE, PLC
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Dates
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Enumeration Date | 01/11/2010
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Last Update Date | 01/11/2010
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Provider Practice Location Address
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Address Line | 305A N MAIN ST
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City | NOBLE
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State | OK
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Zip | 73068-9322
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Country | US
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Telephone | 405-872-9597
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Fax | 405-872-5271
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Provider Business Mailing Address
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Address Line | PO BOX 69
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City | NOBLE
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State | OK
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Zip | 73068-0069
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Country | US
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Telephone | 405-872-9597
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Fax | 405-872-5271
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Authorized Official
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Title or Position | OWNER
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Name | DR. GARY DWAYNE NABORS JR.
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Credential | D.D.S.
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Telephone | 405-872-9597
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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 | 5955
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License Number State | OK
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