MEDICARE: EL RENO DENTAL GROUP PLLC

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	6542	OK

General Provider Information

NPI Number	:	1174054118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL RENO DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	3901 E COVELL RD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-6909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 W ELM ST
Second Line	:
City	:	EL RENO
State	:	OK
Zip	:	73036-4203
Country	:	US
Telephone Number	:	405-262-2289
Fax Number	:

Authorized Official
Title or Position	:	MBR
Name	:	DR. JACOB HIGGINSON
Credential	:	DMD
Telephone Number	:	618-559-3505

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	03/22/2017

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