Provider Demographics
NPI:1316411994
Name:TRICE, CHANEL RENA
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:RENA
Last Name:TRICE
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 1:1024 GATES AVE APT 5I
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-6148
Mailing Address - Country:US
Mailing Address - Phone:931-247-8211
Mailing Address - Fax:
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-7140
Practice Address - Fax:718-613-7270
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY43783841122300000X
NY122300000X
NY13243588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist