Provider Demographics
NPI:1851811293
Name:RED DIRT ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:RED DIRT ORTHODONTICS PLLC
Other - Org Name:BRACES U OKLAHOMA PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOLTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MSD
Authorized Official - Phone:405-227-0054
Mailing Address - Street 1:5940 NW EXPRESSWAY # 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5101
Mailing Address - Country:US
Mailing Address - Phone:405-227-0054
Mailing Address - Fax:970-226-8669
Practice Address - Street 1:5940 NW EXPRESSWAY # 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-5101
Practice Address - Country:US
Practice Address - Phone:405-227-0054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental