Provider Demographics
NPI:1922626639
Name:DENTAL LODGE OF PURCELL
Entity Type:Organization
Organization Name:DENTAL LODGE OF PURCELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-326-8004
Mailing Address - Street 1:1929 S GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1929 S GREEN AVE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-6203
Practice Address - Country:US
Practice Address - Phone:405-294-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental