Provider Demographics
NPI:1932360765
Name:DIXIELAND DENTAL, INC
Entity Type:Organization
Organization Name:DIXIELAND DENTAL, INC
Other - Org Name:NATHAN SHAPARD, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-751-4466
Mailing Address - Street 1:4117 NW 122ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8869
Mailing Address - Country:US
Mailing Address - Phone:405-751-4466
Mailing Address - Fax:405-608-0163
Practice Address - Street 1:4117 NW 122ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8869
Practice Address - Country:US
Practice Address - Phone:405-751-4466
Practice Address - Fax:405-608-0163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200068560AMedicaid