Provider Demographics
NPI:1639895402
Name:DENTAL DEPOT OF 164TH & PORTLAND PLLC
Entity Type:Organization
Organization Name:DENTAL DEPOT OF 164TH & PORTLAND PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF 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:405-409-3789
Mailing Address - Street 1:16401 IRONSTONE PLACE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16401 IRONSTONE PLACE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-900-7123
Practice Address - Fax:405-635-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty