Provider Demographics
NPI:1184035115
Name:MICKELSON, CHACE DERRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHACE
Middle Name:DERRICK
Last Name:MICKELSON
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:PO BOX 3648
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816
Mailing Address - Country:US
Mailing Address - Phone:208-292-0292
Mailing Address - Fax:
Practice Address - Street 1:1090 W PARK PL
Practice Address - Street 2:SUITE B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2785
Practice Address - Country:US
Practice Address - Phone:208-292-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29854122300000X
IDD-4605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist