Provider Demographics
NPI:1275861726
Name:CARRIE L. CHASTAIN D.D.S. PC
Entity Type:Organization
Organization Name:CARRIE L. CHASTAIN D.D.S. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-233-2044
Mailing Address - Street 1:702 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5930
Mailing Address - Country:US
Mailing Address - Phone:580-233-2044
Mailing Address - Fax:
Practice Address - Street 1:702 E PARK ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5930
Practice Address - Country:US
Practice Address - Phone:580-233-2044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064070AMedicaid