Provider Demographics
NPI:1982704417
Name:BRACKETT, RYAN L (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:L
Last Name:BRACKETT
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 1:1300 CROP CIR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-4945
Mailing Address - Country:US
Mailing Address - Phone:405-354-4545
Mailing Address - Fax:405-354-4542
Practice Address - Street 1:1300 CROP CIR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4945
Practice Address - Country:US
Practice Address - Phone:405-354-4545
Practice Address - Fax:405-354-4542
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018800AMedicaid