Healthcare Provider Details

I. General information

NPI: 1285630673
Provider Name (Legal Business Name): RICHARD CHACE JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MORSE BLVD
WINTER PARK FL
32789-3708
US

IV. Provider business mailing address

801 W MORSE BLVD
WINTER PARK FL
32789-3708
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-4404
  • Fax: 407-628-3910
Mailing address:
  • Phone: 407-644-4404
  • Fax: 407-628-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN0005119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: