Provider Demographics
NPI:1013938117
Name:OU CHILDRENS PHYSICIANS DENTAL SERVICE-OUCP DENTAL SERVICE
Entity Type:Organization
Organization Name:OU CHILDRENS PHYSICIANS DENTAL SERVICE-OUCP DENTAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CIESLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:405-271-4750
Mailing Address - Street 1:1200 CHILDRENS AVE STE 8F
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4637
Mailing Address - Country:US
Mailing Address - Phone:405-271-4750
Mailing Address - Fax:405-271-2922
Practice Address - Street 1:1200 CHILDRENS AVE STE 8F
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-4750
Practice Address - Fax:405-271-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749330AMedicaid