MEDICARE: DENTRUST OKLAHOMA, PC

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

General Provider Information

NPI Number	:	1518598267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTRUST OKLAHOMA, PC

Provider Business Mailing Address
First Line	:	6097 EASTON RD
Second Line	:
City	:	PIPERSVILLE
State	:	PA
Zip	:	18947-1810
Country	:	US
Telephone Number	:	267-927-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 1712
Second Line	:	MACOMB RD
City	:	FT.STILL
State	:	OK
Zip	:	73503-4533
Country	:	US
Telephone Number	:	267-927-5000
Fax Number	:	267-927-5000

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	AMANDA CLARK
Credential	:
Telephone Number	:	813-451-4503

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	01/31/2020

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