Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 019025084 | IL |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 019025084 | IL |
NPI | 1205892973 |
---|---|
Provider Name | Dr. Thomas Charles Ocheltree JR. |
First Address | Bloomington, IL 61701-3515 |
Second Address | Bloomington, IL 61701-3515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2006 |
Last Update Date | 01/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019025084 | DENTAL LICENSE NUMBER (01) | IL |