Provider Demographics
NPI:1558003905
Name:BUCCAL UP DENTAL DEER CREEK PLLC
Entity Type:Organization
Organization Name:BUCCAL UP DENTAL DEER CREEK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-960-3070
Mailing Address - Street 1:5314 S YALE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6271
Mailing Address - Country:US
Mailing Address - Phone:918-906-3070
Mailing Address - Fax:
Practice Address - Street 1:12321 HIDDEN FOREST BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2578
Practice Address - Country:US
Practice Address - Phone:405-722-7767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty