Healthcare Provider Details

I. General information

NPI: 1750324901
Provider Name (Legal Business Name): GARY LEE BREECE D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S OAKWOOD RD SUITE A
ENID OK
73703-4945
US

IV. Provider business mailing address

402-A S. OAKWOOD RD SUITE A
ENID OK
73703
US

V. Phone/Fax

Practice location:
  • Phone: 580-233-2557
  • Fax: 580-233-2563
Mailing address:
  • Phone: 580-233-2557
  • Fax: 580-233-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4015
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: