Provider Demographics
NPI:1114449394
Name:SHATTUCK DENTISTRY & BRACES
Entity Type:Organization
Organization Name:SHATTUCK DENTISTRY & BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-326-8004
Mailing Address - Street 1:1523 S. MAIN
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858
Mailing Address - Country:US
Mailing Address - Phone:580-938-2566
Mailing Address - Fax:580-938-2567
Practice Address - Street 1:1523 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-9223
Practice Address - Country:US
Practice Address - Phone:580-938-2566
Practice Address - Fax:580-938-2567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1205032935Medicaid