Basic Information
| Provider Information | |||||||||
| NPI: | 1679072664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAIN STREET DENTAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 FOREST HILL DR | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188455505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 409 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LOCUST GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743525116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188455505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2018 | ||||||||
| LastUpdateDate: | 03/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9184798020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 6531 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.