Provider Demographics
NPI:1366855157
Name:MEAD, ERIC J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:MEAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-0190
Mailing Address - Country:US
Mailing Address - Phone:918-653-4808
Mailing Address - Fax:
Practice Address - Street 1:511 E 2ND ST
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3419
Practice Address - Country:US
Practice Address - Phone:918-653-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK65961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice