Provider Demographics
NPI:1366635849
Name:CHACKO, SANDY ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANDY
Middle Name:ELIZABETH
Last Name:CHACKO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N HIGHLAND AVE NE
Mailing Address - Street 2:APT 3422
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-5609
Mailing Address - Country:US
Mailing Address - Phone:813-453-0499
Mailing Address - Fax:
Practice Address - Street 1:240 N HIGHLAND AVE NE
Practice Address - Street 2:APT 3422
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-5609
Practice Address - Country:US
Practice Address - Phone:813-453-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice