Provider Demographics
NPI:1972114551
Name:BLACK, CHELSEA R (RDH)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62615-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:428 N 8TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615-1006
Practice Address - Country:US
Practice Address - Phone:217-741-8136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL02015698124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist