Provider Demographics
NPI:1689946964
Name:STILLWATER DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:STILLWATER DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-624-3880
Mailing Address - Street 1:1439 S WESTERN RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-6957
Mailing Address - Country:US
Mailing Address - Phone:405-624-3880
Mailing Address - Fax:405-624-3888
Practice Address - Street 1:1439 S WESTERN RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6957
Practice Address - Country:US
Practice Address - Phone:405-624-3880
Practice Address - Fax:405-624-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3939122300000X
OK5802122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty