Chace Derrick Mickelson, D.M.D

Primary specialty

DentistTaxonomy code 122300000X

License

D-4605 Issued in ID

Practice address

1090 W Park PL
Suite B
Coeur D Alene, ID 83814-2785

Phone

(208) 292-0303

NPI assigned

May 13, 2014

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1399939200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1597622400000",
    "number": "1184035115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3648",
            "city": "COEUR D'ALENE",
            "state": "ID",
            "postal_code": "83816",
            "telephone_number": "208-292-0292"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1090 W PARK PL",
            "address_2": "SUITE B",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838142785",
            "telephone_number": "208-292-0303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MICKELSON",
        "first_name": "CHACE",
        "middle_name": "DERRICK",
        "name_prefix": "Dr.",
        "credential": "D.M.D",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-05-13",
        "last_updated": "2020-08-17",
        "certification_date": "2020-08-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "29854",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "ID",
            "license": "D-4605",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Michael G Meza, MD
• Arne E Michalson, MD
• Linda S Michalson, MD
• Pablo Fernando Michel Sanchez, M.D.
• Mickelson-Gates Dentistry PLLC
• Midlife Center
• Brendan A Mielke, MD
• Mike Dusbabek Physical Therapy, PLLC
• Erika M Mikles, PA-C
• Kelly Milbrath, P.T.

• Dentist in Coeur D Alene, ID
• Providers in Coeur D Alene, ID by specialty
• Dentist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.