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General NPI Number Information
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NPI Number | 1881860211
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL ASSOCIATES
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Dates
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Enumeration Date | 05/06/2008
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Last Update Date | 05/06/2008
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Provider Practice Location Address
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Address Line | 1306 N MAIN ST
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City | MIAMI
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State | OK
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Zip | 74354-3325
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Country | US
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Telephone | 918-542-2858
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Fax |
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Provider Business Mailing Address
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Address Line | 1306 N MAIN ST
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City | MIAMI
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State | OK
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Zip | 74354-3325
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | THOMAS B JOURDAN
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Credential |
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Telephone | 918-256-6831
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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 | 5381
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License Number State | OK
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