Dental Depot of 164TH & Portland PLLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

DENTAL DEPOT OF 164TH & PORTLAND PLLC

Practice address

16401 Ironstone Place
Oklahoma City, OK 73013

Phone

(405) 900-7123

Fax

(405) 635-1252

NPI assigned

Oct 13, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Gaylon Zissa

Title

Director of Provider Relations

Phone

(405) 409-3789

Specialties & licenses 1

Addresses

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1665619200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665619200000",
    "number": "1639895402",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16401 IRONSTONE PLACE",
            "city": "OKLAHOMA CITY",
            "state": "OK",
            "postal_code": "73013"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16401 IRONSTONE PLACE",
            "city": "OKLAHOMA CITY",
            "state": "OK",
            "postal_code": "73013",
            "telephone_number": "405-900-7123",
            "fax_number": "405-635-1252"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DENTAL DEPOT OF 164TH & PORTLAND PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-13",
        "last_updated": "2022-10-13",
        "certification_date": "2022-10-07",
        "status": "A",
        "authorized_official_last_name": "ZISSA",
        "authorized_official_first_name": "GAYLON",
        "authorized_official_title_or_position": "DIRECTOR OF PROVIDER RELATIONS",
        "authorized_official_telephone_number": "405-409-3789"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "www.dentaldepot.net",
            "affiliation": "N",
            "address_1": "16401 Ironstone Place",
            "city": "Oklahoma City",
            "state": "OK",
            "country_code": "US",
            "postal_code": "73013",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• General Practice Dentistry in Oklahoma City, OK
• Providers in Oklahoma City, OK by specialty
• General Practice Dentistry in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.