Provider Demographics
NPI:1437310067
Name:PHILLIP W POWELL DDS
Entity Type:Organization
Organization Name:PHILLIP W POWELL DDS
Other - Org Name:WOODWARD FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-256-2600
Mailing Address - Street 1:1222 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801
Mailing Address - Country:US
Mailing Address - Phone:580-256-2600
Mailing Address - Fax:580-256-2671
Practice Address - Street 1:1222 MAIN AVE
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-256-2600
Practice Address - Fax:580-256-2671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100130660AMedicaid