Healthcare Provider Details

I. General information

NPI: 1871889659
Provider Name (Legal Business Name): BRENT KUTLESA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W 15TH ST
EDMOND OK
73013-3603
US

IV. Provider business mailing address

100 W 15TH ST
EDMOND OK
73013-3603
US

V. Phone/Fax

Practice location:
  • Phone: 405-330-2123
  • Fax: 405-285-4695
Mailing address:
  • Phone: 405-330-2123
  • Fax: 405-285-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6288
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: