Basic Information
| Provider Information | |||||||||
| NPI: | 1013453935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORACEK | ||||||||
| FirstName: | JAMIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG. 652 HAMILTON RD | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | FT. SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 29 KETCH CREEK CIR | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735079030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2779 | OK | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 124Q00000X | 01 | OK | HYGIENE | OTHER |