Provider Demographics
NPI:1376693267
Name:DEASON, DAVID
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DEASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2259
Mailing Address - Country:US
Mailing Address - Phone:405-354-4802
Mailing Address - Fax:405-354-4803
Practice Address - Street 1:415 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2259
Practice Address - Country:US
Practice Address - Phone:405-354-4802
Practice Address - Fax:405-354-4803
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK36611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice