Provider Demographics
NPI:1356967079
Name:GLOVER-SECREST, JACY RAE (DDS)
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:RAE
Last Name:GLOVER-SECREST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JACY
Other - Middle Name:R
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9301 STRAKA RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-9630
Mailing Address - Country:US
Mailing Address - Phone:405-623-3735
Mailing Address - Fax:
Practice Address - Street 1:700 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6199
Practice Address - Country:US
Practice Address - Phone:405-912-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT7301122300000X
OK7301122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist