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General NPI Number Information
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NPI Number | 1427839315
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Entity Type | Individual
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Provider Name | SHAUN CHACKO
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Gender | Male
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Dates
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Enumeration Date | 10/09/2023
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 2036 S MILLER LN STE B
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City | CATOOSA
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State | OK
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Zip | 74015-1539
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Country | US
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Telephone | 918-937-7660
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Fax |
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Provider Business Mailing Address
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Address Line | 2714 LAMOND HILL AVE
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City | EDMOND
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State | OK
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Zip | 73034-6979
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Country | US
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Telephone | 405-317-5625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7733
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License Number State | OK
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