Provider Demographics
NPI:1750660700
Name:HENYRETTA DENTAL CENTER 2, PLLC
Entity Type:Organization
Organization Name:HENYRETTA DENTAL CENTER 2, PLLC
Other - Org Name:HENRYETTA DENTAL CENTER, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:9818-652-2555
Mailing Address - Street 1:121 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-5009
Mailing Address - Country:US
Mailing Address - Phone:918-652-2555
Mailing Address - Fax:918-652-2556
Practice Address - Street 1:121 S 6TH ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-5009
Practice Address - Country:US
Practice Address - Phone:918-652-2555
Practice Address - Fax:918-652-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5868261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200085770AMedicaid