Provider Demographics
NPI:1740354398
Name:CHELEMEDOS, RICK A (DDS)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:A
Last Name:CHELEMEDOS
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 1:852 REICHERT AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-4124
Mailing Address - Country:US
Mailing Address - Phone:415-897-9969
Mailing Address - Fax:415-897-6640
Practice Address - Street 1:852 REICHERT AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4124
Practice Address - Country:US
Practice Address - Phone:415-897-9969
Practice Address - Fax:415-897-6640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35691122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8976640AMedicare UPIN