Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 4822 | OK |
N | 204E00000X | Oral & Maxillofacial Surgeon | 4822 | OK |
NPI | 1255591517 |
---|---|
Provider Name | Dr. Gary Lynn Dennington |
First Address | Idabel, OK 74745-7349 |
Second Address | Idabel, OK 74745-7349 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2008 |
Last Update Date | 11/06/2008 |