Organization
PEDIATRIC DENTAL GROUP II, LLC
Active
Parent organization
PEDIATRIC DENTAL GROUP II, LLC
Other names
Adventure Dental of Midwest City
Organization subpart
Yes
Provider details
NPI number
Legal business name
PEDIATRIC DENTAL GROUP II, LLC
Authorized official
SHAUN URBANOZO (CREDENTIALING MANAGER)
(719) 323-2362
Entity
Organization
Contact information
Practice address
1200 S AIR DEPOT BLVD, MIDWEST CITY, OK 73110-4866
(918) 872-7009
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
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3942
OK STATE DENTAL LICENSE
OK
Enumeration date
08/13/2019
Last updated
03/30/2020
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