Provider Demographics
NPI:1548887946
Name:HOMETOWN DENTAL OF YUKON PLLC
Entity type:Organization
Organization Name:HOMETOWN DENTAL OF YUKON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:H
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-831-3202
Mailing Address - Street 1:1600 E 19TH ST STE 504
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6624
Mailing Address - Country:US
Mailing Address - Phone:405-831-3202
Mailing Address - Fax:
Practice Address - Street 1:1315 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-5407
Practice Address - Country:US
Practice Address - Phone:405-494-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty