Healthcare Provider Details

I. General information

NPI: 1689652869
Provider Name (Legal Business Name): CAROLE M DENTINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD SUITE 300
TULSA OK
74146-5229
US

IV. Provider business mailing address

4500 S GARNETT RD SUITE 300
TULSA OK
74146-5229
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-6194
  • Fax: 918-664-0267
Mailing address:
  • Phone: 918-728-6194
  • Fax: 918-664-0267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number14202
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14202R
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29405
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: