Provider Demographics
NPI:1588657563
Name:ROUSE, BRANT PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANT
Middle Name:PHILIP
Last Name:ROUSE
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 1:559 MEADOW CREEK DR
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 DR
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
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice