# LEGACY DENTAL GROUP

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

## Provider details

- **NPI number:** 1831587575
- **Authorized official:** ASHLEY DUSSAULT (OFFICE MANAGER)
- **Authorized official phone:** (405) 513-6630

## Contact information

- **Practice address:** 3901 E COVELL, EDMOND, OK 73034
- **Practice address phone:** (405) 513-6630
- **Practice address fax:** (405) 359-9647
- **Mailing address:** 3901 E COVELL, EDMOND, OK 73034
- **Mailing address phone:** (405) 513-6630
- **Mailing address fax:** (405) 359-9647

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | OK4913 | OK | Yes |
| 122300000X | Dentist | OK6256 | OK | — |

## Other

- **Enumeration date:** 01/05/2015
- **Last updated:** 01/07/2015