Provider Demographics
NPI:1649356569
Name:CASTILLO, ERIC RAY (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:RAY
Last Name:CASTILLO
Suffix:
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 1:1110 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2353
Mailing Address - Country:US
Mailing Address - Phone:580-223-7779
Mailing Address - Fax:580-223-7789
Practice Address - Street 1:1110 WALNUT DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2353
Practice Address - Country:US
Practice Address - Phone:580-223-7779
Practice Address - Fax:580-223-7789
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5652122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200021060AMedicaid