Provider Demographics
NPI: | 1942620893 |
---|---|
Name: | OKC DENTAL HEALTH ASSOCIATES, P.C. |
Entity Type: | Organization |
Organization Name: | OKC DENTAL HEALTH ASSOCIATES, P.C. |
Other - Org Name: | MYDENTIST-ADA |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CREDENTIALING COORDINATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | HANNAH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | FISH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 217-540-5699 |
Mailing Address - Street 1: | 1430 LONNIE ABBOTT BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | ADA |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74820-1851 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1430 LONNIE ABBOTT BLVD |
Practice Address - Street 2: | |
Practice Address - City: | ADA |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74820-1851 |
Practice Address - Country: | US |
Practice Address - Phone: | 580-279-1716 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | OKC DENTAL HEALTH ASSOCIATES, P.C. |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2014-04-18 |
Last Update Date: | 2016-04-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |