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General NPI Number Information
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NPI Number | 1891472304
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Entity Type | Organization
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Legal Business Name | NORTH LAKE DENTAL PLLC
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Dates
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Enumeration Date | 06/28/2023
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Last Update Date | 06/28/2023
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Provider Practice Location Address
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Address Line | 12200 N MACARTHUR BLVD STE 1
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City | OKLAHOMA CITY
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State | OK
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Zip | 73162-1849
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Country | US
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Telephone | 918-998-0996
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Fax |
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Provider Business Mailing Address
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Address Line | 400 RIVERWALK TER STE 250
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City | JENKS
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State | OK
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Zip | 74037-5619
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Country | US
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Telephone | 918-998-0996
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | CANDICE SCHUMANN
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Credential |
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Telephone | 918-998-0996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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