MEDICARE: SKYLER ROBIN PEACOCK DMD

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	7287	OK

General Provider Information

NPI Number	:	1619389350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SKYLER ROBIN PEACOCK DMD

Provider Business Mailing Address
First Line	:	9060 HARMONY DR STE D
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6253
Country	:	US
Telephone Number	:	405-737-8831
Fax Number	:	405-458-8022

Provider Business Practice Location Address
First Line	:	9060 HARMONY DR STE D
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6253
Country	:	US
Telephone Number	:	405-737-8831
Fax Number	:	405-458-8022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	06/16/2020

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