Provider Demographics
NPI:1962816025
Name:FUNK, CHASE A (DDS)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:A
Last Name:FUNK
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 1:1415 FILLMORE ST STE 701
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3346
Mailing Address - Country:US
Mailing Address - Phone:208-735-1415
Mailing Address - Fax:208-733-2757
Practice Address - Street 1:1415 FILLMORE ST STE 701
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3346
Practice Address - Country:US
Practice Address - Phone:208-735-1415
Practice Address - Fax:208-734-7603
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD45821223G0001X
IDD4582ID1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice