Provider Demographics
NPI:1417304742
Name:RUSSELL C. BRORSEN, D.D.S., P.L.L.C.
Entity Type:Organization
Organization Name:RUSSELL C. BRORSEN, D.D.S., P.L.L.C.
Other - Org Name:BRORSEN FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRORSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-372-7474
Mailing Address - Street 1:104 E MCELROY RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3803
Mailing Address - Country:US
Mailing Address - Phone:405-372-7474
Mailing Address - Fax:405-372-7429
Practice Address - Street 1:104 E MCELROY RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3803
Practice Address - Country:US
Practice Address - Phone:405-372-7474
Practice Address - Fax:405-372-7429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty