Provider Demographics
NPI:1316432438
Name:SHAWNEE DENTISTRY AND BRACES
Entity type:Organization
Organization Name:SHAWNEE DENTISTRY AND BRACES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-260-6080
Mailing Address - Street 1:2616 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2838
Mailing Address - Country:US
Mailing Address - Phone:405-275-7730
Mailing Address - Fax:
Practice Address - Street 1:2616 N PARK AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2838
Practice Address - Country:US
Practice Address - Phone:405-275-7730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental