Provider Demographics
NPI:1912172743
Name:RICHARD L. DEVAUGHN D.D.S. INC.
Entity type:Organization
Organization Name:RICHARD L. DEVAUGHN D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-233-2044
Mailing Address - Street 1:702 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5930
Mailing Address - Country:US
Mailing Address - Phone:580-233-2044
Mailing Address - Fax:580-233-1533
Practice Address - Street 1:702 E PARK ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5930
Practice Address - Country:US
Practice Address - Phone:580-233-2044
Practice Address - Fax:580-233-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064070 AMedicaid