Provider Demographics
NPI:1083424592
Name:WALNUT SQUARE DENTAL PARTNERS PLLC
Entity type:Organization
Organization Name:WALNUT SQUARE DENTAL PARTNERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:405-655-9231
Mailing Address - Street 1:2576 W MISSION SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9062
Mailing Address - Country:US
Mailing Address - Phone:405-655-9231
Mailing Address - Fax:
Practice Address - Street 1:2209 W I 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-8249
Practice Address - Country:US
Practice Address - Phone:405-655-9231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty