Basic Information
Provider Information | |||||||||
NPI: | 1548336902 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | SPRING | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SPRING | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | CALDWELL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3919 N MACARTHUR | ||||||||
Address2: |   | ||||||||
City: | WARR ACRES | ||||||||
State: | OK | ||||||||
PostalCode: | 73122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057877827 | ||||||||
FaxNumber: | 4054701838 | ||||||||
Practice Location | |||||||||
Address1: | 3919 N MACARTHUR | ||||||||
Address2: |   | ||||||||
City: | WARR ACRES | ||||||||
State: | OK | ||||||||
PostalCode: | 73122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057877827 | ||||||||
FaxNumber: | 4054701838 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 05/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5799 | OK | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 200057670A | 05 | OK |   | MEDICAID |