Provider Demographics
NPI:1730688912
Name:DYNAMIC DENTAL CENTER
Entity type:Organization
Organization Name:DYNAMIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-269-6921
Mailing Address - Street 1:3000 SW 104TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7041
Mailing Address - Country:US
Mailing Address - Phone:405-703-7070
Mailing Address - Fax:
Practice Address - Street 1:3000 SW 104TH ST STE 5
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7041
Practice Address - Country:US
Practice Address - Phone:405-703-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1981223X0400X
OK61851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty