Provider Demographics
NPI:1790007318
Name:EASY DENTAL 1
Entity Type:Organization
Organization Name:EASY DENTAL 1
Other - Org Name:EASY DENTAL 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LYNDSEY
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-670-3800
Mailing Address - Street 1:4341 SE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3001
Mailing Address - Country:US
Mailing Address - Phone:405-670-3800
Mailing Address - Fax:405-670-3803
Practice Address - Street 1:3727 NW 63RD ST
Practice Address - Street 2:SUITE 112
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1931
Practice Address - Country:US
Practice Address - Phone:405-842-3700
Practice Address - Fax:405-842-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3935261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental