Provider Demographics
NPI:1114192945
Name:DENTAL IMPLANT CENTRE'
Entity Type:Organization
Organization Name:DENTAL IMPLANT CENTRE'
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BULARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-226-0410
Mailing Address - Street 1:2401 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1280
Mailing Address - Country:US
Mailing Address - Phone:580-226-0410
Mailing Address - Fax:580-224-9124
Practice Address - Street 1:2401 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1280
Practice Address - Country:US
Practice Address - Phone:580-226-0410
Practice Address - Fax:580-224-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4684122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty