Provider Demographics
NPI:1699395343
Name:DENTAL SPECIALISTS OF EDMOND
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF EDMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YACOUB
Authorized Official - Middle Name:
Authorized Official - Last Name:AL SAKKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-696-0908
Mailing Address - Street 1:17705 SPARROW HAWK LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-7137
Mailing Address - Country:US
Mailing Address - Phone:405-510-6853
Mailing Address - Fax:
Practice Address - Street 1:16430 MUIRFIELD PL
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-696-0908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1568862357OtherPROVIDER 01
OK1497023196OtherPROVIDER 02