Provider Demographics
NPI:1831325570
Name:DENTAL DEPOT OF MOORE, PLLC
Entity type:Organization
Organization Name:DENTAL DEPOT OF MOORE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:POGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-945-8941
Mailing Address - Street 1:2828 NW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-7404
Mailing Address - Country:US
Mailing Address - Phone:405-799-9123
Mailing Address - Fax:
Practice Address - Street 1:2709 S. I-35 FRONTAGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-799-9123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty