Provider Demographics
NPI:1275773137
Name:THE DENTAL LODGE
Entity Type:Organization
Organization Name:THE DENTAL LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NABORS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:405-872-9597
Mailing Address - Street 1:P.O. BOX 69
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-0069
Mailing Address - Country:US
Mailing Address - Phone:405-972-9597
Mailing Address - Fax:405-872-5271
Practice Address - Street 1:305-A MAIN STREET
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-0069
Practice Address - Country:US
Practice Address - Phone:405-872-9597
Practice Address - Fax:405-872-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty