Provider Demographics
NPI:1649709437
Name:THRALL, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:THRALL
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 1:305 NORTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-2735
Mailing Address - Country:US
Mailing Address - Phone:580-338-5541
Mailing Address - Fax:580-338-5542
Practice Address - Street 1:305 NORTHRIDGE CIR
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-2735
Practice Address - Country:US
Practice Address - Phone:580-338-5541
Practice Address - Fax:580-338-5542
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-094271223G0001X
OK7137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice