Provider Demographics
NPI:1093936924
Name:CITY RESCUE MISSION DENTAL CLINIC
Entity Type:Organization
Organization Name:CITY RESCUE MISSION DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:405-232-2709
Mailing Address - Street 1:800 W CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7807
Mailing Address - Country:US
Mailing Address - Phone:405-232-2709
Mailing Address - Fax:405-236-0341
Practice Address - Street 1:800 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7807
Practice Address - Country:US
Practice Address - Phone:405-232-2709
Practice Address - Fax:405-236-0341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty