Provider Demographics
NPI:1790155521
Name:DERBAUM, CHELSEA (DMD)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:DERBAUM
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 1:172 PERFECT DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2816
Mailing Address - Country:US
Mailing Address - Phone:727-418-0514
Mailing Address - Fax:
Practice Address - Street 1:1511 INDIAN ROCKS RD S
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-4542
Practice Address - Country:US
Practice Address - Phone:727-585-3858
Practice Address - Fax:727-581-0898
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22338122300000X
MADL12757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist