=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033679089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRK, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2019
-----------------------------------------------------
Last Update Date | 03/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7120 S PENNSYLVANIA AVE
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-681-6601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 S MUSTANG RD
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-494-7227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE ADVISOR
-----------------------------------------------------
Name | KRISTEN JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-633-0814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------