Provider Demographics
NPI:1801182944
Name:SORGEN, BRYAN ELLIOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:ELLIOTT
Last Name:SORGEN
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 1:3621 NW 63RD ST STE E
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-2041
Mailing Address - Country:US
Mailing Address - Phone:405-848-8871
Mailing Address - Fax:405-848-4059
Practice Address - Street 1:3621 NW 63RD ST STE E
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-2041
Practice Address - Country:US
Practice Address - Phone:405-848-8871
Practice Address - Fax:405-848-4059
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX270921223G0001X
OK64571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice