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
StateLicense IDTaxonomies
OK57271223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty