Provider Demographics
NPI:1245434166
Name:DENTAL DEPOT MID WEST CITY
Entity type:Organization
Organization Name:DENTAL DEPOT MID WEST CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-737-5123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-737-5123
Mailing Address - Fax:405-737-5125
Practice Address - Street 1:5691 TINKER DIAGONAL
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110
Practice Address - Country:US
Practice Address - Phone:405-737-5123
Practice Address - Fax:405-737-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty