=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275861726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARRIE L. CHASTAIN D.D.S. PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2009
-----------------------------------------------------
Last Update Date | 11/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 E PARK ST
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-5930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-233-2044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 E PARK ST
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-5930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-233-2044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PAULA BOLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-233-2044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5781
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------