Healthcare Provider Details

I. General information

NPI: 1730222811
Provider Name (Legal Business Name): GARY T. BREWER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 E MAIN ST
HEALDTON OK
73438-1801
US

IV. Provider business mailing address

504 E MAIN ST
HEALDTON OK
73438-1801
US

V. Phone/Fax

Practice location:
  • Phone: 580-229-0407
  • Fax: 580-229-0418
Mailing address:
  • Phone: 580-229-0407
  • Fax: 580-229-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY THOMAS BREWER
Title or Position: OWNER
Credential: DDS
Phone: 580-229-0407