Provider Demographics
NPI:1346801198
Name:PROGRESSIVE DENTAL CARE OF TULSA, PLLC
Entity Type:Organization
Organization Name:PROGRESSIVE DENTAL CARE OF TULSA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-702-0708
Mailing Address - Street 1:PO BOX 410168
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-0168
Mailing Address - Country:US
Mailing Address - Phone:214-702-0729
Mailing Address - Fax:
Practice Address - Street 1:7614 E 91ST ST STE 120
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6047
Practice Address - Country:US
Practice Address - Phone:918-477-7774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty