Provider Demographics
NPI:1689652869
Name:DENTINO, CAROLE M (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:M
Last Name:DENTINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-728-6194
Mailing Address - Fax:918-664-0267
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-728-6194
Practice Address - Fax:918-664-0267
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA142022085B0100X
LA14202R2085R0202X
OK294052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14202ROtherMEDICAL LICENSE
LA1104701Medicaid
LA4A681Medicare ID - Type UnspecifiedMEDICARE NUMBER