Provider Demographics
NPI:1083846539
Name:SPEED, JANE MECHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:MECHELLE
Last Name:SPEED
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1069
Mailing Address - Country:US
Mailing Address - Phone:562-810-5752
Mailing Address - Fax:918-453-1339
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-1000
Practice Address - Fax:918-453-1339
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice