Provider Demographics
NPI:1952639478
Name:JACK SELLERS,D.D.S. P.C.
Entity Type:Organization
Organization Name:JACK SELLERS,D.D.S. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:NICHOLS
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-967-4609
Mailing Address - Street 1:103 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1700
Practice Address - Country:US
Practice Address - Phone:918-967-4609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty