Provider Demographics
NPI:1083877179
Name:YOUNGBLOOD, CHASE C (DDS)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:C
Last Name:YOUNGBLOOD
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 1:2025 S GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9005
Mailing Address - Country:US
Mailing Address - Phone:405-307-9704
Mailing Address - Fax:
Practice Address - Street 1:2025 S GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9005
Practice Address - Country:US
Practice Address - Phone:405-307-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist