Provider Demographics
NPI:1548557002
Name:DENTAL PROFESSIONALS OF OKLAHOMA, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF OKLAHOMA, P.C.
Other - Org Name:FAMILY DENTISTRY OF YUKON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:N
Authorized Official - Last Name:PRUEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8434
Mailing Address - Street 1:1670 GARTH BROOKS BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6878
Mailing Address - Country:US
Mailing Address - Phone:405-494-3080
Mailing Address - Fax:405-265-3555
Practice Address - Street 1:1670 GARTH BROOKS BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6878
Practice Address - Country:US
Practice Address - Phone:405-494-3080
Practice Address - Fax:405-265-3555
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF OKLAHOMA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-06
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty