Provider Demographics
NPI:1750688248
Name:CARRIE DS FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:CARRIE DS FAMILY DENTISTRY INC
Other - Org Name:RIVERWALK DENTAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SESSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-392-7654
Mailing Address - Street 1:400 RIVERWALK TERRACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5627
Mailing Address - Country:US
Mailing Address - Phone:918-392-7654
Mailing Address - Fax:918-518-5760
Practice Address - Street 1:400 RIVERWALK TERRACE
Practice Address - Street 2:SUITE 200
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-5627
Practice Address - Country:US
Practice Address - Phone:918-392-7654
Practice Address - Fax:918-518-5760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5239122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6510910001Medicare NSC