Healthcare Provider Details

I. General information

NPI: 1790840536
Provider Name (Legal Business Name): GARY THOMAS BREWER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
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 Number3965
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: