Provider Demographics
NPI:1679072664
Name:MAIN STREET DENTAL, PLLC
Entity Type:Organization
Organization Name:MAIN STREET DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-479-8020
Mailing Address - Street 1:1707 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017
Mailing Address - Country:US
Mailing Address - Phone:918-845-5505
Mailing Address - Fax:
Practice Address - Street 1:409 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352-5116
Practice Address - Country:US
Practice Address - Phone:918-845-5505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6531261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental