Provider Demographics
NPI:1518598267
Name:DENTRUST OKLAHOMA, PC
Entity type:Organization
Organization Name:DENTRUST OKLAHOMA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-451-4503
Mailing Address - Street 1:6097 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:PIPERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18947-1810
Mailing Address - Country:US
Mailing Address - Phone:267-927-5000
Mailing Address - Fax:
Practice Address - Street 1:BLDG 1712
Practice Address - Street 2:MACOMB RD
Practice Address - City:FT.STILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4533
Practice Address - Country:US
Practice Address - Phone:267-927-5000
Practice Address - Fax:267-927-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty