Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5900 | OK |
N | 1223E0200X | Endodontist | 62 | OK |
NPI | 1104833730 |
---|---|
Provider Name | Brandon Scott Rogers |
First Address | Ada, OK 74820 |
Second Address | Ada, OK 74820 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2006 |
Last Update Date | 15/05/2015 |