Provider Demographics
NPI:1043480924
Name:DENTAL GROUP PC
Entity Type:Organization
Organization Name:DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FREDA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-825-7411
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74362-0649
Mailing Address - Country:US
Mailing Address - Phone:918-825-7411
Mailing Address - Fax:918-825-7734
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:STE 110
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-825-7411
Practice Address - Fax:918-825-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty