Provider Demographics
NPI:1578768180
Name:DENTAL DEPOT SOUTH
Entity Type:Organization
Organization Name:DENTAL DEPOT SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GAYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:ZISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-691-1123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-691-1123
Mailing Address - Fax:405-691-2674
Practice Address - Street 1:1024 SW 104TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2990
Practice Address - Country:US
Practice Address - Phone:405-691-1123
Practice Address - Fax:405-691-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200100150AMedicaid