Provider Demographics
NPI:1104206887
Name:PKL ORTHODONTICS, PC
Entity Type:Organization
Organization Name:PKL ORTHODONTICS, PC
Other - Org Name:SKY ORTHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKENS-LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:405-378-4774
Mailing Address - Street 1:717 S I 35 SERVICE RD STE C
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3190
Mailing Address - Country:US
Mailing Address - Phone:405-378-4774
Mailing Address - Fax:
Practice Address - Street 1:717 S I 35 SERVICE RD STE C
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3190
Practice Address - Country:US
Practice Address - Phone:405-378-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK189261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental