Provider Demographics
NPI:1427322361
Name:BLUE AND RED DENTAL LLC
Entity type:Organization
Organization Name:BLUE AND RED DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:PATTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-518-6305
Mailing Address - Street 1:2840 E 101ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-5601
Mailing Address - Country:US
Mailing Address - Phone:918-518-6305
Mailing Address - Fax:918-518-6327
Practice Address - Street 1:2840 E 101ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-5601
Practice Address - Country:US
Practice Address - Phone:918-518-6305
Practice Address - Fax:918-518-6327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5990305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200119910AMedicaid