Provider Demographics
NPI:1861716243
Name:DEDRICK, DARRELL R (DDS)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:R
Last Name:DEDRICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:503 N MAIN
Mailing Address - City:SEILING
Mailing Address - State:OK
Mailing Address - Zip Code:73663-0205
Mailing Address - Country:US
Mailing Address - Phone:580-922-3162
Mailing Address - Fax:580-922-3162
Practice Address - Street 1:503 N. MAIN
Practice Address - Street 2:
Practice Address - City:SEILING
Practice Address - State:OK
Practice Address - Zip Code:73663
Practice Address - Country:US
Practice Address - Phone:580-922-3162
Practice Address - Fax:580-922-3162
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist