MEDICARE: DENTAL PROFESSIONALS OF 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	:	1619729704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF OKLAHOMA, PC

Provider Business Mailing Address
First Line	:	138 SW 134TH ST STE C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-1490
Country	:	US
Telephone Number	:	405-378-5692
Fax Number	:	405-759-2754

Provider Business Practice Location Address
First Line	:	138 SW 134TH ST STE C
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-1490
Country	:	US
Telephone Number	:	405-378-5692
Fax Number	:	405-759-2754

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CEMYIRA MCDOUGAL
Credential	:
Telephone Number	:	217-764-8609

Provider Enumeration Date	:	04/03/2024
Last Update Date	:	04/03/2024

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