Provider Demographics
NPI:1063643484
Name:CHAMBERLAIN, CHELIMO
Entity Type:Individual
Prefix:
First Name:CHELIMO
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-874-0707
Practice Address - Street 1:3070 11TH AVENUE DR SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-8336
Practice Address - Country:US
Practice Address - Phone:828-695-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist