Provider Demographics
NPI:1043836836
Name:SELLERS, CHAD EVAN (DMD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:EVAN
Last Name:SELLERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 W DIVIDE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3464
Mailing Address - Country:US
Mailing Address - Phone:208-515-1466
Mailing Address - Fax:
Practice Address - Street 1:607 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3837
Practice Address - Country:US
Practice Address - Phone:208-466-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-51581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice