Provider Demographics
NPI:1164834701
Name:AFFORDABLE DENTURES-MIDWEST CITY, P.C.
Entity Type:Organization
Organization Name:AFFORDABLE DENTURES-MIDWEST CITY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:FENTEM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-672-0214
Mailing Address - Street 1:5301 MAIN STREET
Mailing Address - Street 2:SUITE 111
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115
Mailing Address - Country:US
Mailing Address - Phone:405-672-0214
Mailing Address - Fax:405-672-0226
Practice Address - Street 1:5301 MAIN STREET
Practice Address - Street 2:SUITE 111
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115
Practice Address - Country:US
Practice Address - Phone:405-672-0214
Practice Address - Fax:405-672-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty