Healthcare Provider Details

I. General information

NPI: 1013571363
Provider Name (Legal Business Name): CHAD L BLACKBURN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3108 NW 150TH ST STE 100
OKLAHOMA CITY OK
73134-2083
US

IV. Provider business mailing address

3108 NW 150TH ST STE 11
OKLAHOMA CITY OK
73134-2083
US

V. Phone/Fax

Practice location:
  • Phone: 405-283-8158
  • Fax:
Mailing address:
  • Phone: 918-774-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7411
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: