MEDICARE: DENTL DEPOT RENO AND ROCKWELL, 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	122300000X	Dentist	3723	OK

General Provider Information

NPI Number	:	1285184119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTL DEPOT RENO AND ROCKWELL, PLLC

Provider Business Mailing Address
First Line	:	2828 NW 30TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-7404
Country	:	US
Telephone Number	:	405-945-8941
Fax Number	:	405-945-8959

Provider Business Practice Location Address
First Line	:	1920 N DREXEL BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73107-3925
Country	:	US
Telephone Number	:	405-945-8941
Fax Number	:	405-945-8959

Authorized Official
Title or Position	:	OWNER / PRESIDENT
Name	:	DR. GLENN ALLEN ASHMORE
Credential	:	DDS
Telephone Number	:	405-945-8941

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	03/17/2021

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