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General NPI Number Information
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NPI Number | 1871872135
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Entity Type | Organization
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Legal Business Name | CUSTOM DENTAL OF NEWCASTLE, PLLC
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Dates
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Enumeration Date | 08/04/2011
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Last Update Date | 08/04/2011
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Provider Practice Location Address
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Address Line | 3290 N TRI-CITY
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City | NEWCASTLE
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State | OK
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Zip | 73065
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Country | US
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Telephone | 405-657-0038
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Fax |
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Provider Business Mailing Address
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Address Line | 3290 N TRI-CITY
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City | NEWCASTLE
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State | OK
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Zip | 73065
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Country | US
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Telephone | 405-657-0038
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | RENE RODGERS
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Credential |
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Telephone | 405-282-6440
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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 | 6098
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License Number State | OR
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