# DENTAL DEPOT OF 63RD & NW EXPRESSWAY, PLLC

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

## Provider details

- **NPI number:** 1861058877
- **Authorized official:** DR. GLENN ALLAN ASHMORE DDS (OWNER / PRESIDENT)
- **Authorized official phone:** (405) 591-3123

## Contact information

- **Practice address:** 4025 NW 63RD STREET, OKLAHOMA CITY, OK 73116
- **Practice address phone:** (405) 591-3123
- **Practice address fax:** (405) 653-1714
- **Mailing address:** 2828 NW 30TH ST, OKLAHOMA CITY, OK 73112-7404
- **Mailing address phone:** (405) 591-3123
- **Mailing address fax:** (405) 653-1714

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 05/15/2019
- **Last updated:** 06/25/2021