Provider Demographics
NPI:1407412992
Name:DENTAL DEPOT SOUTHERN HILLS 71ST & JACKSON
Entity Type:Organization
Organization Name:DENTAL DEPOT SOUTHERN HILLS 71ST & JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:ASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-236-7123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:918-236-7123
Mailing Address - Fax:918-998-0818
Practice Address - Street 1:710 W 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1825
Practice Address - Country:US
Practice Address - Phone:918-236-7123
Practice Address - Fax:918-998-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088170AMedicaid