Provider Demographics
NPI:1730662040
Name:BULLOCK, CHANDLER (DMD)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:BULLOCK
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 1:6217 OAKMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2812
Mailing Address - Country:US
Mailing Address - Phone:682-224-1464
Mailing Address - Fax:
Practice Address - Street 1:6217 OAKMONT BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-2812
Practice Address - Country:US
Practice Address - Phone:682-224-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist