Provider Demographics
NPI:1003236969
Name:OKC DENTAL HEALTH ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:OKC DENTAL HEALTH ASSOCIATES, P.C.
Other - Org Name:PEBBLE CREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:DETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8921
Mailing Address - Street 1:1041 E. HWY 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1041 E. HWY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064
Practice Address - Country:US
Practice Address - Phone:405-256-0037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-18
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty