Healthcare Provider Details

I. General information

NPI: 1932269933
Provider Name (Legal Business Name): CHARLES R. KEITHLINE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 E 13TH ST
TULSA OK
74120-5207
US

IV. Provider business mailing address

1421 E 13TH ST
TULSA OK
74120-5207
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-3744
  • Fax: 918-585-3774
Mailing address:
  • Phone: 918-585-3744
  • Fax: 918-585-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3942
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: