=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295979417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESAPEAKE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2009
-----------------------------------------------------
Last Update Date | 05/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 NW 58TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73118-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-218-2570
-----------------------------------------------------
Fax | 405-218-2561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 NW 58TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73118-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-218-2570
-----------------------------------------------------
Fax | 405-218-2561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANA PRICE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 405-218-2570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5493
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------