# DENTAL DEPOT OF 10004 SOUTH MEMORIAL DRIVE PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699028597
- **Authorized official:** DR. GLENN ALLEN ASHMORE DDS (OWNER/PRESIDENT)
- **Authorized official phone:** (405) 949-0123

## Contact information

- **Practice address:** 1918 N. DREXEL, OKLAHOMA CITY, OK 73107
- **Practice address phone:** (918) 209-5123
- **Practice address fax:** (918) 209-5124
- **Mailing address:** 2828 NW 30TH ST, OKLAHOMA CITY, OK 73112-7404
- **Mailing address phone:** (918) 209-5123
- **Mailing address fax:** (918) 209-5124

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | — | Yes |

## Other

- **Enumeration date:** 10/17/2012
- **Last updated:** 06/25/2021