Provider Demographics
NPI:1770838237
Name:CHIDECKEL, ROBERT MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARK
Last Name:CHIDECKEL
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 1:155 CAPITOL SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ZIA PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87053-6013
Mailing Address - Country:US
Mailing Address - Phone:505-867-5258
Mailing Address - Fax:505-771-9452
Practice Address - Street 1:155 CAPITOL SQUARE DR
Practice Address - Street 2:
Practice Address - City:ZIA PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87053-6013
Practice Address - Country:US
Practice Address - Phone:505-867-5258
Practice Address - Fax:505-771-9452
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022107L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist