Healthcare Provider Details

I. General information

NPI: 1992802508
Provider Name (Legal Business Name): DR. BRIAN RAY SHAFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W WATTS ST
EL RENO OK
73036-4458
US

IV. Provider business mailing address

701 W WATTS ST
EL RENO OK
73036-4458
US

V. Phone/Fax

Practice location:
  • Phone: 405-262-2739
  • Fax: 405-262-2905
Mailing address:
  • Phone: 405-262-2739
  • Fax: 405-262-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5388
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: