Provider Demographics
NPI:1386872117
Name:BRISOLARA, ROBERT KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEITH
Last Name:BRISOLARA
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 1:6888 E 133 RD
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-9020
Mailing Address - Country:US
Mailing Address - Phone:405-379-6400
Mailing Address - Fax:405-379-3364
Practice Address - Street 1:6888 E 133 AVE.
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-9020
Practice Address - Country:US
Practice Address - Phone:405-379-6400
Practice Address - Fax:405-379-3364
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist