Provider Demographics
NPI:1558744995
Name:FAMILY DENTISTRY
Entity Type:Organization
Organization Name:FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:QUINT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-762-5624
Mailing Address - Street 1:1618 N 5TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2764
Mailing Address - Country:US
Mailing Address - Phone:580-762-5624
Mailing Address - Fax:
Practice Address - Street 1:1618 N 5TH ST STE 2
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2764
Practice Address - Country:US
Practice Address - Phone:580-762-5624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty