Provider Demographics
NPI:1780001636
Name:DENTAL DEPOT OF BROKEN ARROW, PLLC
Entity type:Organization
Organization Name:DENTAL DEPOT OF BROKEN ARROW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:ASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-949-0123
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-945-8941
Mailing Address - Fax:405-945-8959
Practice Address - Street 1:1950 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8944
Practice Address - Country:US
Practice Address - Phone:405-945-8941
Practice Address - Fax:405-945-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty