Provider Demographics
NPI:1043328594
Name:SPIVA, CHAD DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:DOUGLAS
Last Name:SPIVA
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 1:808 NE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160
Mailing Address - Country:US
Mailing Address - Phone:405-799-5529
Mailing Address - Fax:405-799-8223
Practice Address - Street 1:808 NE 19TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-799-5529
Practice Address - Fax:405-799-8223
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5497122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist