Provider Demographics
NPI:1417624578
Name:DENTAL DEPOT OF I-44 & GARNETT, PLLC
Entity Type:Organization
Organization Name:DENTAL DEPOT OF I-44 & GARNETT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GAYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:ZISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-945-8941
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:539-476-5123
Mailing Address - Fax:539-222-2516
Practice Address - Street 1:1302 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1825
Practice Address - Country:US
Practice Address - Phone:539-476-5123
Practice Address - Fax:539-222-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty