Provider Demographics
NPI:1134273576
Name:BROCKMEIER, DANIEL W (DMD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:BROCKMEIER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 NW 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73122-7345
Mailing Address - Country:US
Mailing Address - Phone:405-262-7631
Mailing Address - Fax:405-262-8099
Practice Address - Street 1:1631 A EAST HWY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-7631
Practice Address - Fax:405-262-8099
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1305260Medicaid