Organization
DENTAL DEPOT SOUTH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GAYLON ZISSA (DIRECTOR PROVIDER RELATIONS)
(405) 691-1123
Entity
Organization
Contact information
Practice address
1024 SW 104TH ST, OKLAHOMA CITY, OK 73139-2990
(405) 691-1123
(405) 691-2674
Mailing address
2828 NW 30TH ST, OKLAHOMA CITY, OK 73112-7404
(405) 691-1123
(405) 691-2674
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200100150A
—
OK
Enumeration date
06/15/2007
Last updated
06/25/2021
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