Provider Demographics
NPI:1063051795
Name:LONE GROVE DENTISTRY & BRACES
Entity type:Organization
Organization Name:LONE GROVE DENTISTRY & BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-375-5855
Mailing Address - Street 1:16931 US HIGHWAY 70
Mailing Address - Street 2:
Mailing Address - City:LONE GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:73443-6523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16931 US HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:LONE GROVE
Practice Address - State:OK
Practice Address - Zip Code:73443-6523
Practice Address - Country:US
Practice Address - Phone:580-657-3117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-28
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental