Provider Demographics
NPI:1275798373
Name:BREWER, MICHAEL L (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BREWER
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:PO BOX 1227
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-1227
Mailing Address - Country:US
Mailing Address - Phone:918-266-3866
Mailing Address - Fax:918-266-3880
Practice Address - Street 1:1755 N HIGHWAY 66
Practice Address - Street 2:SUITE # D
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2409
Practice Address - Country:US
Practice Address - Phone:918-266-3866
Practice Address - Fax:918-266-3880
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice