MEDICARE: PURCELL FAMILY DENTAL LLC

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	:	1790491538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURCELL FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	5700 SE 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-6017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 W TRUMAN PL
Second Line	:
City	:	PURCELL
State	:	OK
Zip	:	73080-3209
Country	:	US
Telephone Number	:	405-942-4445
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRAD NELSON
Credential	:
Telephone Number	:	405-260-6080

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	02/05/2024

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Directions to “PURCELL FAMILY DENTAL LLC ” Practice Location

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