Healthcare Provider Details

I. General information

NPI: 1326052721
Provider Name (Legal Business Name): CLIFFORD CHURCH CHAPIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 7TH ST
MEEKER CO
81641
US

IV. Provider business mailing address

PO BOX 161 341 7TH ST
MEEKER CO
81641
US

V. Phone/Fax

Practice location:
  • Phone: 970-878-3696
  • Fax: 970-878-3696
Mailing address:
  • Phone: 970-878-3696
  • Fax: 970-878-3696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105030
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: