MEDICARE: LEGACY FAMILY DENTIST, 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	261QD0000X	Dental Clinic/Center	6026	OK

General Provider Information

NPI Number	:	1518250265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY FAMILY DENTIST, PLLC.

Provider Business Mailing Address
First Line	:	8470 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-6009
Country	:	US
Telephone Number	:	405-728-8400
Fax Number	:	405-720-1777

Provider Business Practice Location Address
First Line	:	8470 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-6009
Country	:	US
Telephone Number	:	405-728-8400
Fax Number	:	405-720-1777

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. ALAN FORTENBERRY
Credential	:	D.D.S.
Telephone Number	:	405-728-8400

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	05/26/2011

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