=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063125375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MSDG PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 E 91ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74137-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-496-2481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3920 E 91ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74137-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-496-2481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ DENTIST
-----------------------------------------------------
Name | JOSHUA V BRASHER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 405-250-2255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------