Basic Information
| Provider Information | |||||||||
| NPI: | 1568791440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISICK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 WETZEL AVE | ||||||||
| Address2: | BLDG 815 | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195242843 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 WETZEL AVE | ||||||||
| Address2: | BLDG 815 | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | 7195242843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2009 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30-022838 | OH | N | Dental Providers | Dentist | 122300000X | 59659 | CA | N | Dental Providers | Dentist | 122300000X | DE60198298 | WA | N | Dental Providers | Dentist | 122300000X | RES.2658 | OH | N | Dental Providers | Dentist | 122300000X | DEN.00106346 | CO | Y | Dental Providers | Dentist |
No ID Information.