Provider Demographics
NPI:1235141029
Name:EAGLE DENTAL CORP INC
Entity Type:Organization
Organization Name:EAGLE DENTAL CORP INC
Other - Org Name:DR STEVE CARSON AND DR MARY MARY MARTIN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-732-6821
Mailing Address - Street 1:6520 EAST RENO
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2109
Mailing Address - Country:US
Mailing Address - Phone:405-732-6821
Mailing Address - Fax:405-732-7970
Practice Address - Street 1:6520 EAST RENO
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2109
Practice Address - Country:US
Practice Address - Phone:405-732-6821
Practice Address - Fax:405-732-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4594122300000X
OK4609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty