Provider Demographics
NPI:1962865949
Name:EASY DENTAL SOLUTIONS IV
Entity Type:Organization
Organization Name:EASY DENTAL SOLUTIONS IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-376-6565
Mailing Address - Street 1:10001 S PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE M 220
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6923
Mailing Address - Country:US
Mailing Address - Phone:405-796-8012
Mailing Address - Fax:405-378-2381
Practice Address - Street 1:1100 N MUSTANG RD
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7201
Practice Address - Country:US
Practice Address - Phone:405-376-6565
Practice Address - Fax:405-376-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty