Provider Demographics
NPI:1114052032
Name:FORT GIBSON FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:FORT GIBSON FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-478-4433
Mailing Address - Street 1:801 S LEE ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434
Mailing Address - Country:US
Mailing Address - Phone:918-478-4433
Mailing Address - Fax:918-478-4066
Practice Address - Street 1:801 S LEE ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-8710
Practice Address - Country:US
Practice Address - Phone:918-478-4433
Practice Address - Fax:918-478-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty