MEDICARE: BETHANY DENTAL GROUP 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	122300000X	Dentist	6256	OK

General Provider Information

NPI Number	:	1265984066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETHANY DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	6301 NW 23RD ST
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-5931
Country	:	US
Telephone Number	:	405-474-6362
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 NW 23RD ST
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-5931
Country	:	US
Telephone Number	:	405-474-6362
Fax Number	:

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

Provider Enumeration Date	:	10/27/2016
Last Update Date	:	10/27/2016

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