Provider Demographics
NPI:1366685810
Name:CHATELAIN, KOURT BEAU (DMD)
Entity Type:Individual
Prefix:DR
First Name:KOURT
Middle Name:BEAU
Last Name:CHATELAIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 TURTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1937
Mailing Address - Country:US
Mailing Address - Phone:903-592-1664
Mailing Address - Fax:903-525-1099
Practice Address - Street 1:805 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1937
Practice Address - Country:US
Practice Address - Phone:903-592-1664
Practice Address - Fax:903-525-1099
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX286771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28677OtherTEXAS DENTAL LICENSE
TX32475102Medicaid