Organization
NICOMA PARK DENTAL PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JASON WALLACE DDS (OWNER)
(405) 413-7466
Entity
Organization
Contact information
Practice address
10420 NE 23RD ST, OKLAHOMA CITY, OK 73141-5216
(405) 603-8520
Mailing address
3801 N BRYAN AVE, BETHANY, OK 73008-3001
(405) 413-7466
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
06/27/2018
Last updated
06/27/2018
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