Healthcare Provider Details

I. General information

NPI: 1649342064
Provider Name (Legal Business Name): DR. JOSE ANTONIO CHACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 LANDERBROOK DR STE 250
MAYFIELD HTS OH
44124-6502
US

IV. Provider business mailing address

125 E 13TH ST # 1405
CHICAGO IL
60605-2655
US

V. Phone/Fax

Practice location:
  • Phone: 800-487-4867
  • Fax: 216-593-7533
Mailing address:
  • Phone: 312-834-0521
  • Fax: 312-834-0521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number019-026092
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: