Provider Demographics
NPI:1518250265
Name:LEGACY FAMILY DENTIST, PLLC.
Entity Type:Organization
Organization Name:LEGACY FAMILY DENTIST, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-728-8400
Mailing Address - Street 1:8470 NW EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-6009
Mailing Address - Country:US
Mailing Address - Phone:405-728-8400
Mailing Address - Fax:405-720-1777
Practice Address - Street 1:8470 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-6009
Practice Address - Country:US
Practice Address - Phone:405-728-8400
Practice Address - Fax:405-720-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6026261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental