Healthcare Provider Details

I. General information

NPI: 1962738328
Provider Name (Legal Business Name): DIANA BLAIR DRVOSTEP D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

PO BOX 1069
TAHLEQUAH OK
74465-1069
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-1000
  • Fax: 918-453-1339
Mailing address:
  • Phone: 562-810-5752
  • Fax: 918-453-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6101
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: