Provider Demographics
NPI:1831490960
Name:CANTWELL DENTAL CLINIC, PC
Entity Type:Organization
Organization Name:CANTWELL DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-542-3700
Mailing Address - Street 1:109 1/2 EAST MAIN STREET
Mailing Address - Street 2:BOX 1002
Mailing Address - City:HINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73047-1002
Mailing Address - Country:US
Mailing Address - Phone:405-542-3700
Mailing Address - Fax:405-542-3785
Practice Address - Street 1:109 1/2 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:OK
Practice Address - Zip Code:73047-1002
Practice Address - Country:US
Practice Address - Phone:405-542-3700
Practice Address - Fax:405-542-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty