Organization
LEGACY DENTAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ASHLEY DUSSAULT (OFFICE MANAGER)
(405) 513-6630
Entity
Organization
Contact information
Practice address
3901 E COVELL, EDMOND, OK 73034
(405) 513-6630
(405) 359-9647
Mailing address
3901 E COVELL, EDMOND, OK 73034
(405) 513-6630
(405) 359-9647
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
OK4913
OK
122300000X
Dentist
OK6256
OK
Other
Enumeration date
01/05/2015
Last updated
01/07/2015
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