Provider Demographics
NPI:1124144555
Name:PRUETT, GEOFFREY ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:ALLEN
Last Name:PRUETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W MEMORIAL RD STE 809
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8305
Mailing Address - Country:US
Mailing Address - Phone:405-755-2670
Mailing Address - Fax:
Practice Address - Street 1:4200 W MEMORIAL RD STE 809
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8305
Practice Address - Country:US
Practice Address - Phone:405-755-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK34821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice