Provider Demographics
NPI: | 1508155250 |
---|---|
Name: | ROBERT D MARS DDS INC |
Entity Type: | Organization |
Organization Name: | ROBERT D MARS DDS INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | JANICE |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | BROWN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 405-691-3399 |
Mailing Address - Street 1: | 1512 SW 89TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | OKLAHOMA CITY |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 73159-6307 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 405-691-3399 |
Mailing Address - Fax: | 405-691-4092 |
Practice Address - Street 1: | 1512 SW 89TH ST |
Practice Address - Street 2: | |
Practice Address - City: | OKLAHOMA CITY |
Practice Address - State: | OK |
Practice Address - Zip Code: | 73159-6307 |
Practice Address - Country: | US |
Practice Address - Phone: | 405-691-3399 |
Practice Address - Fax: | 405-691-4092 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-04-04 |
Last Update Date: | 2011-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | 4525 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |