Provider Demographics
NPI:1427839315
Name:CHACKO, SHAUN
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 LAMOND HILL AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6979
Mailing Address - Country:US
Mailing Address - Phone:405-317-5625
Mailing Address - Fax:
Practice Address - Street 1:2036 S MILLER LN STE B
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-1539
Practice Address - Country:US
Practice Address - Phone:918-937-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK77331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice