Provider Demographics
NPI:1205892973
Name:OCHELTREE, THOMAS CHARLES JR (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLES
Last Name:OCHELTREE
Suffix:JR
Gender:M
Credentials:DMD
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Mailing Address - Street 1:109 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3515
Mailing Address - Country:US
Mailing Address - Phone:309-663-2526
Mailing Address - Fax:309-663-4788
Practice Address - Street 1:109 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3515
Practice Address - Country:US
Practice Address - Phone:309-663-2526
Practice Address - Fax:309-663-4788
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190250841223S0112X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019025084OtherDENTAL LICENSE NUMBER