Healthcare Provider Details

I. General information

NPI: 1063341964
Provider Name (Legal Business Name): CHELSEY CHACKO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 W LUMSDEN RD
BRANDON FL
33511-6261
US

IV. Provider business mailing address

1983 ORANGE CT
DUNEDIN FL
34698-9423
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-7888
  • Fax:
Mailing address:
  • Phone: 224-247-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberPENDINGAPPLICATION
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: