Healthcare Provider Details

I. General information

NPI: 1447092580
Provider Name (Legal Business Name): CHELSIE LO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25155 N 67TH AVE STE 142
PHOENIX AZ
85083-1065
US

IV. Provider business mailing address

2269 W ECHO LN
PHOENIX AZ
85021-4285
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-6767
  • Fax:
Mailing address:
  • Phone: 510-283-8659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012197
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012197
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: