Provider Demographics
NPI:1992550958
Name:PATRICK, PRESTON KEITH
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:KEITH
Last Name:PATRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CENTRAL PARK DR APT 1214
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-1747
Mailing Address - Country:US
Mailing Address - Phone:918-822-2268
Mailing Address - Fax:
Practice Address - Street 1:6616 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1708
Practice Address - Country:US
Practice Address - Phone:405-601-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist