Basic Information
| Provider Information | |||||||||
| NPI: | 1184035115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKELSON | ||||||||
| FirstName: | CHACE | ||||||||
| MiddleName: | DERRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3648 | ||||||||
| Address2: | |||||||||
| City: | COEUR D'ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920292 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1090 W PARK PL | ||||||||
| Address2: | SUITE B | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920303 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2014 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 29854 | TX | N | Dental Providers | Dentist | 122300000X | D-4605 | ID | Y | Dental Providers | Dentist |
No ID Information.