Provider Demographics
NPI:1467639146
Name:DOUGLAS C.CHANCELLOR D.D.S.P.C.
Entity Type:Organization
Organization Name:DOUGLAS C.CHANCELLOR D.D.S.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANCELLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-348-5254
Mailing Address - Street 1:2603 PAWNEE XING
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6882
Mailing Address - Country:US
Mailing Address - Phone:405-348-5254
Mailing Address - Fax:
Practice Address - Street 1:4440 NW EXPRESSWAY
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1533
Practice Address - Country:US
Practice Address - Phone:405-848-4442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4404261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100117130Medicaid