Provider Demographics
NPI:1548526106
Name:MUSKOGEE DENTAL GROUP, INC.
Entity type:Organization
Organization Name:MUSKOGEE DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-682-0544
Mailing Address - Street 1:2909 AZALEA PARK DR
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2283
Mailing Address - Country:US
Mailing Address - Phone:918-682-0544
Mailing Address - Fax:918-682-1004
Practice Address - Street 1:2909 AZALEA PARK DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2283
Practice Address - Country:US
Practice Address - Phone:918-682-0544
Practice Address - Fax:918-682-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty