Healthcare Provider Details

I. General information

NPI: 1114639408
Provider Name (Legal Business Name): SONA ELIZABETH CHACKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117 SW 93RD AVE
COOPER CITY FL
33328-4222
US

IV. Provider business mailing address

5117 SW 93RD AVE
COOPER CITY FL
33328-4222
US

V. Phone/Fax

Practice location:
  • Phone: 954-309-4338
  • Fax:
Mailing address:
  • Phone: 954-306-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number29038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: