1629084587 NPI number — MR. BRADFORD DYER OVERTON DDS

Table of content: MR. BRADFORD DYER OVERTON DDS (NPI 1629084587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629084587 NPI number — MR. BRADFORD DYER OVERTON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVERTON
Provider First Name:
BRADFORD
Provider Middle Name:
DYER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OVERTON
Provider Other First Name:
BRADFORD
Provider Other Middle Name:
DYER
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1629084587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 S ELM PL
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-5369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-258-2323
Provider Business Mailing Address Fax Number:
918-258-0425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 S ELM PL
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74012-5369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-258-2323
Provider Business Practice Location Address Fax Number:
918-258-0425
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4551 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)