Provider Demographics
NPI:1578357372
Name:SHOCK, KYRA JORDAN (DDS)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:JORDAN
Last Name:SHOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 INTREPID CIR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4300
Mailing Address - Country:US
Mailing Address - Phone:405-808-4522
Mailing Address - Fax:
Practice Address - Street 1:4409 INTREPID CIR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4300
Practice Address - Country:US
Practice Address - Phone:405-808-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14459122300000X
VA0401419518122300000X
MD18769122300000X
NC14377122300000X
MA10000721122300000X
VT016.0134368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist