MEDICARE: PREMIER DENTAL OF WESTERN OKLAHOMA, 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	1223G0001X	General Practice Dentistry	5614	OK

General Provider Information

NPI Number	:	1790959757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DENTAL OF WESTERN OKLAHOMA, PLLC

Provider Business Mailing Address
First Line	:	3102 S HIGHWAY 6
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-9779
Country	:	US
Telephone Number	:	580-225-4448
Fax Number	:	580-225-4460

Provider Business Practice Location Address
First Line	:	3102 S HIGHWAY 6
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-9779
Country	:	US
Telephone Number	:	580-225-4448
Fax Number	:	580-225-4460

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. PATRICK PETE STOVER
Credential	:	DDS
Telephone Number	:	580-225-4448

Provider Enumeration Date	:	04/21/2008
Last Update Date	:	04/21/2008

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