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General NPI Number Information
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NPI Number | 1164835617
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Entity Type | Organization
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Legal Business Name | DENTAL LODGE AT BROOKHAVE
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Dates
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Enumeration Date | 06/03/2014
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Last Update Date | 06/03/2014
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Provider Practice Location Address
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Address Line | 3700 W ROBINSON ST SUITE 102
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City | NORMAN
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State | OK
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Zip | 73072-3659
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Country | US
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Telephone | 405-872-9597
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 69
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City | NOBLE
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State | OK
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Zip | 73068-0069
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Country | US
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Telephone | 405-872-9597
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GARY D NABORS JR.
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Credential | D.D.S.
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Telephone | 405-872-9597
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5955
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License Number State | OK
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