Provider Demographics
NPI:1013438100
Name:SLACK, BRYCE E
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:E
Last Name:SLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 E 133RD ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-1200
Mailing Address - Country:US
Mailing Address - Phone:435-773-7175
Mailing Address - Fax:
Practice Address - Street 1:101 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-3625
Practice Address - Country:US
Practice Address - Phone:918-825-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2023-05-10
Deactivation Date:2023-04-17
Deactivation Code:
Reactivation Date:2023-05-10
Provider Licenses
StateLicense IDTaxonomies
OK69791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice