Provider Demographics
NPI:1831587575
Name:LEGACY DENTAL GROUP
Entity type:Organization
Organization Name:LEGACY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSSAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-513-6630
Mailing Address - Street 1:3901 E COVELL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034
Mailing Address - Country:US
Mailing Address - Phone:405-513-6630
Mailing Address - Fax:405-359-9647
Practice Address - Street 1:3901 E COVELL
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-513-6630
Practice Address - Fax:405-359-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK6256122300000X
OKOK4913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty