MEDICARE: CMH DENTAL

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	5788	OK

General Provider Information

NPI Number	:	1184895153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CMH DENTAL

Provider Business Mailing Address
First Line	:	416 S MUSTANG RD
Second Line	:	SUITE A
City	:	YUKON
State	:	OK
Zip	:	73099-7314
Country	:	US
Telephone Number	:	405-265-3131
Fax Number	:	405-265-2479

Provider Business Practice Location Address
First Line	:	416 S MUSTANG RD
Second Line	:	SUITE A
City	:	YUKON
State	:	OK
Zip	:	73099-7314
Country	:	US
Telephone Number	:	405-265-3131
Fax Number	:	405-265-2479

Authorized Official
Title or Position	:	OWNER
Name	:	DR. COURTNEY MARLENE HOUSLEY
Credential	:	DDS
Telephone Number	:	405-265-3131

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	06/30/2008

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