1962726851 NPI number — BLAIRE ALLYN ERSTENIUK DDS MS

Table of content: BLAIRE ALLYN ERSTENIUK DDS MS (NPI 1962726851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962726851 NPI number — BLAIRE ALLYN ERSTENIUK DDS MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERSTENIUK
Provider First Name:
BLAIRE
Provider Middle Name:
ALLYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOWERS
Provider Other First Name:
BLAIRE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS MS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1962726851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 S KELLY AVE STE A1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73003-5696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-509-8932
Provider Business Mailing Address Fax Number:
405-531-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 S KELLY AVE STE A1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73003-5696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-509-8932
Provider Business Practice Location Address Fax Number:
405-531-0808
Provider Enumeration Date:
03/21/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  6184 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 6184 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)