Provider Demographics
NPI:1366787699
Name:BRENT T. AMAYA D.D.S. P.L.L.C.
Entity type:Organization
Organization Name:BRENT T. AMAYA D.D.S. P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:AMAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-737-6622
Mailing Address - Street 1:1991 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6225
Mailing Address - Country:US
Mailing Address - Phone:405-737-6622
Mailing Address - Fax:405-733-2250
Practice Address - Street 1:1991 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6225
Practice Address - Country:US
Practice Address - Phone:405-737-6622
Practice Address - Fax:405-733-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK62731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty