Provider Demographics
NPI:1932269933
Name:KEITHLINE, CHARLES R (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:KEITHLINE
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 1:1421 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5207
Mailing Address - Country:US
Mailing Address - Phone:918-585-3744
Mailing Address - Fax:918-585-3774
Practice Address - Street 1:1421 E 13TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5207
Practice Address - Country:US
Practice Address - Phone:918-585-3744
Practice Address - Fax:918-585-3774
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry