Provider Demographics
NPI:1811642770
Name:DENTAL DEPOT OF 83RD & UNION HILLS PLLC
Entity type:Organization
Organization Name:DENTAL DEPOT OF 83RD & UNION HILLS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GAYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:ZISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-945-8941
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:623-887-1123
Mailing Address - Fax:623-278-0252
Practice Address - Street 1:18855 N 83RD AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2806
Practice Address - Country:US
Practice Address - Phone:623-887-1123
Practice Address - Fax:623-278-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty