1639269152 NPI number — DR. MARY ELLEN SULLIVAN CHALMERS D.M.D.

Table of content: DR. MARY ELLEN SULLIVAN CHALMERS D.M.D. (NPI 1639269152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639269152 NPI number — DR. MARY ELLEN SULLIVAN CHALMERS D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHALMERS
Provider First Name:
MARY ELLEN
Provider Middle Name:
SULLIVAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639269152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 MONTGOMERY DR
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95404-6630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-545-5440
Provider Business Mailing Address Fax Number:
707-545-4040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 MONTGOMERY DR
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-6630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-545-5440
Provider Business Practice Location Address Fax Number:
707-545-4040
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  29829 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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