Provider Demographics
NPI:1962726851
Name:ERSTENIUK, BLAIRE ALLYN (DDS MS)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:ALLYN
Last Name:ERSTENIUK
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:BLAIRE
Other - Middle Name:
Other - Last Name:BOWERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS
Mailing Address - Street 1:609 S KELLY AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5696
Mailing Address - Country:US
Mailing Address - Phone:405-509-8932
Mailing Address - Fax:405-531-0808
Practice Address - Street 1:609 S KELLY AVE STE A1
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5696
Practice Address - Country:US
Practice Address - Phone:405-509-8932
Practice Address - Fax:405-531-0808
Is Sole Proprietor?:No
Enumeration Date:2010-03-21
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61841223P0300X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program