Provider Demographics
NPI:1740653930
Name:CUSTOM DENTAL SOUTH OKLAHOMA CITY
Entity type:Organization
Organization Name:CUSTOM DENTAL SOUTH OKLAHOMA CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:NAIL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:405-631-7571
Mailing Address - Street 1:6800 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1809
Mailing Address - Country:US
Mailing Address - Phone:405-631-7571
Mailing Address - Fax:
Practice Address - Street 1:6800 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1809
Practice Address - Country:US
Practice Address - Phone:405-631-7571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200592780AMedicaid