MEDICARE: C.BRANT WORTHINGTON DDD INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	5-3257	OK

General Provider Information

NPI Number	:	1477727568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C.BRANT WORTHINGTON DDD INC.

Provider Business Mailing Address
First Line	:	7901 NE 10TH ST
Second Line	:	SUITE 103
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73110-3600
Country	:	US
Telephone Number	:	405-737-0404
Fax Number	:	405-737-0934

Provider Business Practice Location Address
First Line	:	7901 NE 10TH ST
Second Line	:	SUITE 103
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73110-3600
Country	:	US
Telephone Number	:	405-737-0404
Fax Number	:	405-737-0934

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. C. BRANT WORTHINGTON
Credential	:	DDS
Telephone Number	:	405-737-0404

Provider Enumeration Date	:	04/18/2008
Last Update Date	:	04/18/2008

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