Provider Demographics
NPI:1154544187
Name:DENTAL CARE OF MUSKOGEE, INC.
Entity type:Organization
Organization Name:DENTAL CARE OF MUSKOGEE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:DR
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-682-5518
Mailing Address - Street 1:2406 E. SHAWNEE AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1561
Mailing Address - Country:US
Mailing Address - Phone:918-682-5518
Mailing Address - Fax:918-683-0410
Practice Address - Street 1:2406 E. SHAWNEE AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1561
Practice Address - Country:US
Practice Address - Phone:918-682-5518
Practice Address - Fax:918-683-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40471223G0001X
OK5961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100054210AMedicaid
OK200030980AMedicaid