Healthcare Provider Details

I. General information

NPI: 1336700327
Provider Name (Legal Business Name): CHELSEA DIAMOND DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W JERICHO TPKE
HUNTINGTON STATION NY
11746-3649
US

IV. Provider business mailing address

135 W JERICHO TPKE
HUNTINGTON STATION NY
11746-3649
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-5900
  • Fax:
Mailing address:
  • Phone: 631-424-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35158
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number062329
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: