Provider Demographics
NPI:1043816671
Name:ALTUS MANGUM DENTAL PLLC
Entity Type:Organization
Organization Name:ALTUS MANGUM DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SETHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-482-3974
Mailing Address - Street 1:1410 1/2 N LOUIS TITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-2218
Mailing Address - Country:US
Mailing Address - Phone:580-782-5513
Mailing Address - Fax:
Practice Address - Street 1:907 FALCON RD
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-2833
Practice Address - Country:US
Practice Address - Phone:580-482-3974
Practice Address - Fax:580-482-0800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALTUS MANGUM DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1223G0001XOtherGENERAL DENTIST