MEDICARE: SDPMWC, 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

General Provider Information

NPI Number	:	1538739610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SDPMWC, 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	:	918-310-1056

Provider Business Practice Location Address
First Line	:	1900 S AIR DEPOT BLVD STE 1B
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-5522
Country	:	US
Telephone Number	:	405-733-3553
Fax Number	:	405-733-5002

Authorized Official
Title or Position	:	CFO
Name	:	MIKE YATES
Credential	:
Telephone Number	:	918-998-0996

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	08/17/2022

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