Basic Information
| Provider Information | |||||||||
| NPI: | 1528262441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DENTAL DEPOT HEFNER STATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 NW 30TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731127404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057220123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7130 WEST HEFNER ROAD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057220123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOLDSCLEW | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4057220123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3723 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.