MEDICARE: OKC 89TH DENTAL, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215470497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKC 89TH DENTAL, PLLC

Provider Business Mailing Address
First Line	:	400 RIVERWALK TER STE 250
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-5619
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:	918-235-9079

Provider Business Practice Location Address
First Line	:	7801 S WESTERN AVE STE 101
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-2411
Country	:	US
Telephone Number	:	405-691-3399
Fax Number	:	405-256-1191

Authorized Official
Title or Position	:	OWNER
Name	:	CREED LOUIS CARDON
Credential	:	DDS
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	11/21/2016
Last Update Date	:	08/12/2020

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