Provider Demographics
NPI:1568791440
Name:CHISICK, MICHAEL CHRISTOPHER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:CHISICK
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 1:1631 WETZEL AVE
Mailing Address - Street 2:BLDG 815
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4095
Mailing Address - Country:US
Mailing Address - Phone:719-526-5537
Mailing Address - Fax:719-524-2843
Practice Address - Street 1:1631 WETZEL AVE
Practice Address - Street 2:BLDG 815
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4095
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:719-524-2843
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022838122300000X
CA59659122300000X
WADE60198298122300000X
OHRES.2658122300000X
CODEN.00106346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist