Basic Information
Provider Information | |||||||||
NPI: | 1548887946 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOMETOWN DENTAL OF YUKON PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 E 19TH ST STE 504 | ||||||||
Address2: |   | ||||||||
City: | EDMOND | ||||||||
State: | OK | ||||||||
PostalCode: | 730136624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058313202 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1315 HOLLY AVE | ||||||||
Address2: |   | ||||||||
City: | YUKON | ||||||||
State: | OK | ||||||||
PostalCode: | 730995407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4054948006 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2020 | ||||||||
LastUpdateDate: | 07/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | BOBBY | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4058313202 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.