Provider Demographics
NPI:1588779524
Name:COERVER, BRIAN DAMIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAMIAN
Last Name:COERVER
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 1:1401 ARLINGTON
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2636
Mailing Address - Country:US
Mailing Address - Phone:580-332-4872
Mailing Address - Fax:580-436-1971
Practice Address - Street 1:1401 ARLINGTON
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2636
Practice Address - Country:US
Practice Address - Phone:580-332-4872
Practice Address - Fax:580-436-1971
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100177730AMedicaid