Provider Demographics
NPI:1487154829
Name:PROUD TO SERVE FAMILY DENTISTRY
Entity type:Organization
Organization Name:PROUD TO SERVE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MAY-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-309-7721
Mailing Address - Street 1:10550 GLAD LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-6983
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6401 N INTERSTATE DR STE 156
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-9524
Practice Address - Country:US
Practice Address - Phone:405-309-7721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200422540AMedicaid