Provider Demographics
NPI:1164535183
Name:ADOLPH FAMILY DENTISTRY INC
Entity type:Organization
Organization Name:ADOLPH FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:ADOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-756-0270
Mailing Address - Street 1:112 N GRAND
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447
Mailing Address - Country:US
Mailing Address - Phone:918-756-0270
Mailing Address - Fax:918-756-0283
Practice Address - Street 1:112 N GRAND
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-756-0270
Practice Address - Fax:918-756-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty