Provider Demographics
NPI:1992849996
Name:KINGFISHER DENTAL PLLC
Entity Type:Organization
Organization Name:KINGFISHER DENTAL PLLC
Other - Org Name:KINGFISHER DENTISTRY AND BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-375-5855
Mailing Address - Street 1:9060 HARMONY DR
Mailing Address - Street 2:STE E
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130
Mailing Address - Country:US
Mailing Address - Phone:405-594-8844
Mailing Address - Fax:405-485-8043
Practice Address - Street 1:100 STARLITE DR
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750
Practice Address - Country:US
Practice Address - Phone:405-375-5855
Practice Address - Fax:405-358-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200208490AMedicaid