Provider Demographics
NPI:1235419409
Name:EDMOND PEDIATRIC AND TEEN DENTISTRY
Entity Type:Organization
Organization Name:EDMOND PEDIATRIC AND TEEN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT, OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-513-8811
Mailing Address - Street 1:3824 S. BOULEVARD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-513-8811
Mailing Address - Fax:
Practice Address - Street 1:3824 S. BOULEVARD
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-513-8811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty