Provider Demographics
NPI:1346762564
Name:MUSTANG DENTISTRY & BRACES
Entity Type:Organization
Organization Name:MUSTANG DENTISTRY & BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-326-8004
Mailing Address - Street 1:1001 E HIGHWAY 152
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064
Mailing Address - Country:US
Mailing Address - Phone:405-353-1388
Mailing Address - Fax:
Practice Address - Street 1:1001 E. HIGHWAY 152
Practice Address - Street 2:SUITE 113
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064
Practice Address - Country:US
Practice Address - Phone:405-353-1388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6076261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1205032935Medicaid