Provider Demographics
NPI:1467551150
Name:CHELENZA, NICHOLAS JOSEPH JR (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:CHELENZA
Suffix:JR
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 1:4417 W GORE BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5978
Mailing Address - Country:US
Mailing Address - Phone:580-248-8418
Mailing Address - Fax:580-248-4118
Practice Address - Street 1:4417 W GORE BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5978
Practice Address - Country:US
Practice Address - Phone:580-248-8418
Practice Address - Fax:580-248-4118
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100011060AMedicaid