Provider Demographics
NPI:1265902183
Name:SHANKLE DENTAL-BROKEN ARROW PLLC
Entity type:Organization
Organization Name:SHANKLE DENTAL-BROKEN ARROW PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-960-3070
Mailing Address - Street 1:5314 S YALE AVE.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-960-3070
Mailing Address - Fax:
Practice Address - Street 1:2522 E KENOSHA ST.
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-6712
Practice Address - Country:US
Practice Address - Phone:918-355-1391
Practice Address - Fax:918-355-4135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty