Provider Demographics
NPI:1407560535
Name:DENTRUST OKLAHOMA, PC
Entity Type:Organization
Organization Name:DENTRUST OKLAHOMA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-362-5938
Mailing Address - Street 1:3360 N AVE BLDG 685
Mailing Address - Street 2:
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145-9028
Mailing Address - Country:US
Mailing Address - Phone:267-927-5000
Mailing Address - Fax:267-927-5001
Practice Address - Street 1:3360 N AVE BLDG 685
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-9028
Practice Address - Country:US
Practice Address - Phone:267-927-5000
Practice Address - Fax:267-927-5001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTRUST OKLAHOMA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty