Provider Demographics
NPI:1740455674
Name:LAVALLEY DENTAL CARE, INC.
Entity type:Organization
Organization Name:LAVALLEY DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:LYNNETTE
Authorized Official - Last Name:LAVALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-2700
Mailing Address - Street 1:300 E HIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-4060
Mailing Address - Country:US
Mailing Address - Phone:405-379-2700
Mailing Address - Fax:
Practice Address - Street 1:300 E HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-4060
Practice Address - Country:US
Practice Address - Phone:405-379-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100097210AMedicaid