Provider Demographics
NPI:1053740563
Name:COMPLETE COSMETIC CARE DENTISTRY
Entity type:Organization
Organization Name:COMPLETE COSMETIC CARE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAMANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-216-1000
Mailing Address - Street 1:12136 S YUKON AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6621
Mailing Address - Country:US
Mailing Address - Phone:918-216-1000
Mailing Address - Fax:918-216-1100
Practice Address - Street 1:12136 S YUKON AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6621
Practice Address - Country:US
Practice Address - Phone:918-216-1000
Practice Address - Fax:918-216-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200201950AMedicaid