Provider Demographics
NPI:1740455245
Name:SIGNATURE DENTAL, INC
Entity type:Organization
Organization Name:SIGNATURE DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL-POORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-943-0123
Mailing Address - Street 1:2620 NW EXPRESSWAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7281
Mailing Address - Country:US
Mailing Address - Phone:405-943-0123
Mailing Address - Fax:405-945-0234
Practice Address - Street 1:2620 NW EXPRESSWAY
Practice Address - Street 2:SUITE E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7281
Practice Address - Country:US
Practice Address - Phone:405-943-0123
Practice Address - Fax:405-945-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5877261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200084850AMedicaid