Provider Demographics
NPI:1003131459
Name:BRANT ROUSE DDS PLC
Entity Type:Organization
Organization Name:BRANT ROUSE DDS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-456-0977
Mailing Address - Street 1:559 MEADOW CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1088
Mailing Address - Country:US
Mailing Address - Phone:918-456-0977
Mailing Address - Fax:855-856-5958
Practice Address - Street 1:559 MEADOW CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-1088
Practice Address - Country:US
Practice Address - Phone:918-456-0977
Practice Address - Fax:855-856-5958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200081330AMedicaid