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General NPI Number Information
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NPI Number | 1972151587
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Entity Type | Organization
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Legal Business Name | LAKECREST DENTAL-OWASSO 96TH
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Dates
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Enumeration Date | 08/27/2019
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 9551 N. OWASSO EXPRESSWAY SUITE #100
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City | OWASSO
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State | OK
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Zip | 74055
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Country | US
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Telephone | 918-376-6165
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Fax | 918-376-6160
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Provider Business Mailing Address
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Address Line | 9551 N. OWASSO EXPY SUITE 100
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City | OWASSO
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State | OK
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Zip | 74055
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Country | US
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Telephone | 918-376-6165
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Fax | 918-376-6160
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MICHELLE MAYRE MOSS
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Credential |
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Telephone | 918-376-6165
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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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