Provider Demographics
NPI:1598790495
Name:BEAVER, BRANDON E (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:E
Last Name:BEAVER
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 1:2915 WESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2028
Mailing Address - Country:US
Mailing Address - Phone:580-924-1234
Mailing Address - Fax:580-920-2082
Practice Address - Street 1:2915 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2028
Practice Address - Country:US
Practice Address - Phone:580-924-1234
Practice Address - Fax:580-920-2082
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK55971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200045860AMedicaid