Provider Demographics
NPI:1013211846
Name:CUSTOM DENTAL OF EDMOND, PLLC
Entity Type:Organization
Organization Name:CUSTOM DENTAL OF EDMOND, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:PITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-282-6440
Mailing Address - Street 1:17840 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9097
Mailing Address - Country:US
Mailing Address - Phone:405-282-6440
Mailing Address - Fax:405-282-6785
Practice Address - Street 1:17840 N. PENN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73012
Practice Address - Country:US
Practice Address - Phone:405-282-6440
Practice Address - Fax:405-282-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty