Provider Demographics
NPI:1790840536
Name:BREWER, GARY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:THOMAS
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 1:504 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEALDTON
Mailing Address - State:OK
Mailing Address - Zip Code:73438-1801
Mailing Address - Country:US
Mailing Address - Phone:580-229-0407
Mailing Address - Fax:580-229-0418
Practice Address - Street 1:504 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HEALDTON
Practice Address - State:OK
Practice Address - Zip Code:73438-1801
Practice Address - Country:US
Practice Address - Phone:580-229-0407
Practice Address - Fax:580-229-0418
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice