Provider Demographics
NPI:1902184757
Name:IM, CHANDARA (DDS)
Entity Type:Individual
Prefix:
First Name:CHANDARA
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16421 N 150TH DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-1473
Mailing Address - Country:US
Mailing Address - Phone:480-560-7603
Mailing Address - Fax:
Practice Address - Street 1:ARIZONA 264
Practice Address - Street 2:SAGE MEMORIAL HOSPITAL
Practice Address - City:GANADO
Practice Address - State:AZ
Practice Address - Zip Code:86505
Practice Address - Country:US
Practice Address - Phone:928-755-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist