Provider Demographics
NPI:1679075147
Name:YUKON DENTAL GROUP PLLC
Entity type:Organization
Organization Name:YUKON DENTAL GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:XU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-982-2121
Mailing Address - Street 1:1621 MIDTOWN PLACE STE. B
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130
Mailing Address - Country:US
Mailing Address - Phone:405-982-2121
Mailing Address - Fax:
Practice Address - Street 1:1010 GARTH BROOKS BLVD STE. 120
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-982-2121
Practice Address - Fax:405-561-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty