MEDICARE: SOUTHRIDGE DENTAL ARTS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1174007736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHRIDGE DENTAL ARTS PLLC

Provider Business Mailing Address
First Line	:	3901 E COVELL RD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73034-6909
Country	:	US
Telephone Number	:	405-474-6362
Fax Number	:

Provider Business Practice Location Address
First Line	:	8383 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5249
Country	:	US
Telephone Number	:	405-474-6362
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSHUA BRASHER
Credential	:	DDS
Telephone Number	:	405-474-6362

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	09/19/2018

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