Organization
PEDIATRIC DENTAL GROUP II, LLC
Active
Other names
Pediatric Dental Group II, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
SHAUN URBANOZO (CREDENTIALING MANAGER)
(719) 323-2362
Entity
Organization
Contact information
Practice address
7715 E 91ST ST STE A, TULSA, OK 74133-6060
(918) 585-3744
Mailing address
2221 E BIJOU ST STE 100, COLORADO SPRINGS, CO 80909-8009
(719) 576-1850
(719) 955-3470
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
32
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3942
OK DENTAL LICENSE
OK
Enumeration date
06/22/2015
Last updated
03/30/2020
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