Basic Information
| Provider Information | |||||||||
| NPI: | 1104833730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5900 | OK | Y | Dental Providers | Dentist | 1223E0200X | 62 | OK | N | Dental Providers | Dentist | Endodontics |
No ID Information.