Provider Demographics
NPI:1902299233
Name:MOSHER, BRADY HALL (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:HALL
Last Name:MOSHER
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 W 81ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2900
Mailing Address - Country:US
Mailing Address - Phone:918-917-4777
Mailing Address - Fax:
Practice Address - Street 1:1531 W 81ST ST STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-2900
Practice Address - Country:US
Practice Address - Phone:918-917-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6787122300000X
OK7493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist