MEDICARE: CUSTOM DENTAL SOUTH OKLAHOMA CITY

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	122300000X	Dentist	6745	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740653930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM DENTAL SOUTH OKLAHOMA CITY

Provider Business Mailing Address
First Line	:	6800 S WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-1809
Country	:	US
Telephone Number	:	405-631-7571
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 S WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-1809
Country	:	US
Telephone Number	:	405-631-7571
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	CARSON LOUIS NAIL
Credential	:	DMD
Telephone Number	:	405-631-7571

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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Directions to “CUSTOM DENTAL SOUTH OKLAHOMA CITY ” Practice Location

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