Provider Demographics
NPI:1053360297
Name:CHILDREN'S DENTAL CLINIC OF OKLAHOMA CITY, PLLC
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC OF OKLAHOMA CITY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0343
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:309 SW 59TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-8321
Practice Address - Country:US
Practice Address - Phone:405-631-2700
Practice Address - Fax:405-631-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200039080AMedicaid