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General NPI Number Information
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NPI Number | 1831587575
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Entity Type | Organization
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Legal Business Name | LEGACY DENTAL GROUP
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/07/2015
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Provider Practice Location Address
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Address Line | 3901 E COVELL
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City | EDMOND
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State | OK
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Zip | 73034
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Country | US
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Telephone | 405-513-6630
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Fax | 405-359-9647
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Provider Business Mailing Address
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Address Line | 3901 E COVELL
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City | EDMOND
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State | OK
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Zip | 73034
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Country | US
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Telephone | 405-513-6630
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Fax | 405-359-9647
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ASHLEY DUSSAULT
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Credential |
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Telephone | 405-513-6630
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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 | OK6256
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | OK4913
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License Number State | OK
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