Provider Demographics
NPI:1396945358
Name:PICKENS-LARSON, PRISCILLA (DMD)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:PICKENS-LARSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S I 35 SERVICE RD STE C
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3190
Mailing Address - Country:US
Mailing Address - Phone:405-378-4774
Mailing Address - Fax:405-378-4775
Practice Address - Street 1:717 S I 35 SERVICE RD STE C
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3190
Practice Address - Country:US
Practice Address - Phone:405-378-4774
Practice Address - Fax:405-378-4775
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254161223X0400X
OKSPECIALTYLICENSE#1891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics