Provider Demographics
NPI:1871872135
Name:CUSTOM DENTAL OF NEWCASTLE, PLLC
Entity type:Organization
Organization Name:CUSTOM DENTAL OF NEWCASTLE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-282-6440
Mailing Address - Street 1:3290 N TRI-CITY
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065
Mailing Address - Country:US
Mailing Address - Phone:405-657-0038
Mailing Address - Fax:
Practice Address - Street 1:3290 N TRI-CITY
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065
Practice Address - Country:US
Practice Address - Phone:405-657-0038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty