Healthcare Provider Details

I. General information

NPI: 1962702555
Provider Name (Legal Business Name): ABSOLUTE SMILES FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 E. HWY. 37
TUTTLE OK
73089
US

IV. Provider business mailing address

4800 E. HWY. 37
TUTTLE OK
73089
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-0900
  • Fax: 405-381-0902
Mailing address:
  • Phone: 405-381-0900
  • Fax: 405-381-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5944
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier200115890A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MR. BRIAN G. CHASTAIN
Title or Position: OWNER
Credential: DDS
Phone: 405-381-0900