Provider Demographics
NPI:1033631841
Name:EL RENO DENTAL
Entity Type:Organization
Organization Name:EL RENO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-326-8004
Mailing Address - Street 1:9060 HARMONY DR STE E
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6253
Mailing Address - Country:US
Mailing Address - Phone:405-262-1919
Mailing Address - Fax:405-563-9374
Practice Address - Street 1:1601 INVESTORS AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-1919
Practice Address - Fax:405-563-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6076261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental