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General NPI Number Information
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NPI Number | 1447099734
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Entity Type | Individual
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Provider Name | INDRAJA CHACKO DDS
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Gender | Female
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Dates
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Enumeration Date | 05/24/2024
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Last Update Date | 05/24/2024
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Provider Practice Location Address
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Address Line | 16401 IRONSTONE DR
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City | EDMOND
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State | OK
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Zip | 73013-6088
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Country | US
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Telephone | 405-784-4822
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Fax |
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Provider Business Mailing Address
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Address Line | 1921 DEL SIMMONS DR
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City | EDMOND
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State | OK
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Zip | 73003-2427
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Country | US
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Telephone | 405-719-9160
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 7869
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License Number State | OK
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