Basic Information
| Provider Information | |||||||||
| NPI: | 1750353686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHACON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | DEANA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 RIDGELEY RD | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574512415 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | NAVAL MEDICAL CENTER PORTSMOUTH | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579535000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | D11173 | MN | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.