Provider Demographics
NPI:1902371958
Name:UNIVERSITY FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:UNIVERSITY FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MACK
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-844-6333
Mailing Address - Street 1:775 W COVELL RD STE 160
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2302
Mailing Address - Country:US
Mailing Address - Phone:405-844-6333
Mailing Address - Fax:
Practice Address - Street 1:20 E DUNLOUP RD STE A
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-3201
Practice Address - Country:US
Practice Address - Phone:405-275-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental