Provider Demographics
NPI:1073719209
Name:BROWN, NATHAN KELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:KELLY
Last Name:BROWN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 S FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750
Mailing Address - Country:US
Mailing Address - Phone:405-375-5855
Mailing Address - Fax:
Practice Address - Street 1:2302 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750
Practice Address - Country:US
Practice Address - Phone:405-375-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice