Provider Demographics
NPI:1760536866
Name:PEDICORD, DAVID W (DDS MDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:PEDICORD
Suffix:
Gender:M
Credentials:DDS MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 E 67TH STREET
Mailing Address - Street 2:STE 208
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-491-5888
Mailing Address - Fax:918-491-5883
Practice Address - Street 1:4606 E 67TH STREET
Practice Address - Street 2:SUITE 208
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-491-5888
Practice Address - Fax:918-491-5883
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK37061223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics