Provider Demographics
NPI:1689331753
Name:COFFEE CREEK PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:COFFEE CREEK PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-562-2222
Mailing Address - Street 1:2800 N KELLY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3004
Mailing Address - Country:US
Mailing Address - Phone:405-562-2222
Mailing Address - Fax:
Practice Address - Street 1:2800 N KELLY AVE STE 200
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3004
Practice Address - Country:US
Practice Address - Phone:405-562-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty