Provider Demographics
NPI:1962738328
Name:DRVOSTEP, DIANA BLAIR (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:BLAIR
Last Name:DRVOSTEP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1069
Mailing Address - Country:US
Mailing Address - Phone:562-810-5752
Mailing Address - Fax:918-453-1339
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-1000
Practice Address - Fax:918-453-1339
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6101122300000X
NC112331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Yes122300000XDental ProvidersDentist