Provider Demographics
NPI:1649000605
Name:DENTAL PROFESSIONALS OF OKLAHOMA, PC
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF OKLAHOMA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:711 SW 19TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2966
Mailing Address - Country:US
Mailing Address - Phone:405-913-7622
Mailing Address - Fax:
Practice Address - Street 1:711 SW 19TH ST STE 100
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2966
Practice Address - Country:US
Practice Address - Phone:405-913-7622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF OKLAHOMA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty