Provider Demographics
NPI:1265984066
Name:BETHANY DENTAL GROUP PLLC
Entity type:Organization
Organization Name:BETHANY DENTAL GROUP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-474-6362
Mailing Address - Street 1:6301 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5931
Mailing Address - Country:US
Mailing Address - Phone:405-474-6362
Mailing Address - Fax:
Practice Address - Street 1:6301 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5931
Practice Address - Country:US
Practice Address - Phone:405-474-6362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty