Provider Demographics
NPI:1841636586
Name:BRORSEN, RUSSELL CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CHARLES
Last Name:BRORSEN
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 1:1605 S SANGRE RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1847
Mailing Address - Country:US
Mailing Address - Phone:405-880-8313
Mailing Address - Fax:405-880-8369
Practice Address - Street 1:1605 S SANGRE RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1847
Practice Address - Country:US
Practice Address - Phone:405-880-8313
Practice Address - Fax:405-880-8369
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice