Provider Demographics
NPI:1275915878
Name:DESSO, CHASE L (LAC)
Entity Type:Individual
Prefix:MR
First Name:CHASE
Middle Name:L
Last Name:DESSO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7442 HEALDSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3323
Mailing Address - Country:US
Mailing Address - Phone:707-861-8930
Mailing Address - Fax:
Practice Address - Street 1:7765 HEALDSBURG AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3309
Practice Address - Country:US
Practice Address - Phone:707-861-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16569171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist