Provider Demographics
NPI: | 1629211594 |
---|---|
Name: | OWASSO PERIODONTICS AND DENTAL IMPLANTS |
Entity Type: | Organization |
Organization Name: | OWASSO PERIODONTICS AND DENTAL IMPLANTS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PERIODONTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DAVID |
Authorized Official - Middle Name: | T |
Authorized Official - Last Name: | STAPLETON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 918-376-2191 |
Mailing Address - Street 1: | 14600 E 88TH PL N |
Mailing Address - Street 2: | |
Mailing Address - City: | OWASSO |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74055-4877 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 918-376-2191 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 14600 E 88TH PL N |
Practice Address - Street 2: | |
Practice Address - City: | OWASSO |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74055-4877 |
Practice Address - Country: | US |
Practice Address - Phone: | 918-376-2191 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-04-08 |
Last Update Date: | 2009-04-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | 5727 | 1223P0300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0300X | Dental Providers | Dentist | Periodontics | Group - Single Specialty |