Provider Demographics
NPI:1316458383
Name:SOUTH SOONER DENTAL PARTNERS
Entity type:Organization
Organization Name:SOUTH SOONER DENTAL PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:405-384-7071
Mailing Address - Street 1:1060 SW 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2494
Mailing Address - Country:US
Mailing Address - Phone:405-384-7071
Mailing Address - Fax:
Practice Address - Street 1:1060 SW 4TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-384-7071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629595046OtherDOCTOR NPI