Provider Demographics
NPI:1427344738
Name:STORTS FAMILY DENTISTRY, JESSE D. STORTS, JR. PC
Entity type:Organization
Organization Name:STORTS FAMILY DENTISTRY, JESSE D. STORTS, JR. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISTS
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:STORTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-223-6720
Mailing Address - Street 1:1220 MERRICK DR.
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401
Mailing Address - Country:US
Mailing Address - Phone:580-223-6720
Mailing Address - Fax:580-223-6724
Practice Address - Street 1:1220 MERRICK DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1824
Practice Address - Country:US
Practice Address - Phone:580-223-6720
Practice Address - Fax:580-223-6724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty