Provider Demographics
NPI:1649413865
Name:DECANO, DEXTER DE GUZMAN (PT)
Entity Type:Individual
Prefix:MR
First Name:DEXTER
Middle Name:DE GUZMAN
Last Name:DECANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SW PARKRIDGE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7575
Mailing Address - Country:US
Mailing Address - Phone:580-248-5668
Mailing Address - Fax:580-248-0785
Practice Address - Street 1:1401 SW PARKRIDGE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7575
Practice Address - Country:US
Practice Address - Phone:580-248-5668
Practice Address - Fax:580-248-0785
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist