Provider Demographics
NPI:1235169129
Name:CHILDREN'S DENTAL CLINIC OF OKLAHOMA CITY AT PORTLAND PLAZA, PLLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC OF OKLAHOMA CITY AT PORTLAND PLAZA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LICENSING & CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0342
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:
Practice Address - Street 1:3637 NW 39TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6309
Practice Address - Country:US
Practice Address - Phone:405-942-7755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty