Provider Demographics
NPI:1003196239
Name:DENTAL DEPOT 62ND & SOUTH WESTERN PLLC
Entity Type:Organization
Organization Name:DENTAL DEPOT 62ND & SOUTH WESTERN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-949-0123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-606-7123
Mailing Address - Fax:405-606-7130
Practice Address - Street 1:6217 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1605
Practice Address - Country:US
Practice Address - Phone:405-606-7123
Practice Address - Fax:405-606-7130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty