Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 5214 | OK |
NPI | 1013025477 |
---|---|
Provider Name | Dr. Carl Todd Bridges |
First Address | Lawton, OK 73505 |
Second Address | Lawton, OK 73505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
731496013001 | BCBS OK (01) | OK |