MEDICARE: DENTAL SQUARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6727	OK

General Provider Information

NPI Number	:	1164979076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SQUARE LLC

Provider Business Mailing Address
First Line	:	6301 NW 23RD ST
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-5931
Country	:	US
Telephone Number	:	405-495-2402
Fax Number	:	405-495-1325

Provider Business Practice Location Address
First Line	:	6301 NW 23RD ST
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-5931
Country	:	US
Telephone Number	:	405-495-2402
Fax Number	:	405-495-1325

Authorized Official
Title or Position	:	CEO
Name	:	ANUSHA KONERU
Credential	:	DDS
Telephone Number	:	405-495-2402

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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Directions to “DENTAL SQUARE LLC ” Practice Location

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