Provider Demographics
NPI:1831429042
Name:DENTAL LODGE, PLC
Entity type:Organization
Organization Name:DENTAL LODGE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:NABORS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-872-9597
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-0069
Mailing Address - Country:US
Mailing Address - Phone:405-872-9597
Mailing Address - Fax:405-872-5271
Practice Address - Street 1:305A N MAIN ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-9322
Practice Address - Country:US
Practice Address - Phone:405-872-9597
Practice Address - Fax:405-872-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty