Provider Demographics
NPI:1629084587
Name:OVERTON, BRADFORD DYER (DDS)
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:DYER
Last Name:OVERTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MR
Other - First Name:BRADFORD
Other - Middle Name:DYER
Other - Last Name:OVERTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:817 S ELM PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-258-2323
Mailing Address - Fax:918-258-0425
Practice Address - Street 1:817 S ELM PL
Practice Address - Street 2:SUITE 102
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-258-2323
Practice Address - Fax:918-258-0425
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice