Provider Demographics
NPI:1457612798
Name:MODERN DENTAL PROFESSIONALS - OKLAHOMA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS - OKLAHOMA PC
Other - Org Name:MONARCH DENTAL - QUAL SPRINGS
Other - Org Type:Other Name
Authorized Official - Title/Position:PC OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-212-8135
Mailing Address - Street 1:6501 WINDCREST DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3087
Mailing Address - Country:US
Mailing Address - Phone:972-212-8135
Mailing Address - Fax:972-767-4885
Practice Address - Street 1:13710 N PENNSYLVANIA AVE
Practice Address - Street 2:STE. #1
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6030
Practice Address - Country:US
Practice Address - Phone:972-212-8135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty