Provider Demographics
NPI:1750514329
Name:PROUD, NATHAN N (DDS)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:N
Last Name:PROUD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W. BENJAMIN HOLT DR.
Mailing Address - Street 2:BLDG. B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:6002 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1602
Practice Address - Country:US
Practice Address - Phone:405-631-9100
Practice Address - Fax:405-631-4672
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice