Provider Demographics
NPI:1407838113
Name:EDMOND DENTAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:EDMOND DENTAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:V. RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-341-8804
Mailing Address - Street 1:PO BOX 7326
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-7326
Mailing Address - Country:US
Mailing Address - Phone:405-341-8804
Mailing Address - Fax:405-341-4967
Practice Address - Street 1:950 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3024
Practice Address - Country:US
Practice Address - Phone:405-341-8804
Practice Address - Fax:405-341-4967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4715 AND 59691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty