Individual
DR. CHACE DERRICK MICKELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D
Contact information
Practice address
1090 W PARK PL, SUITE B, COEUR D ALENE, ID 83814-2785
(208) 292-0303
Mailing address
PO BOX 3648, COEUR D'ALENE, ID 83816
(208) 292-0292
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
29854
TX
122300000X
Dentist
Primary
D-4605
ID
Other
Enumeration date
05/13/2014
Last updated
08/17/2020
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