Provider Demographics
NPI:1902948599
Name:COLEMAN, CHALICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHALICE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 S WENTWORTH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-6300
Mailing Address - Country:US
Mailing Address - Phone:773-548-8200
Mailing Address - Fax:773-538-8683
Practice Address - Street 1:5401 S WENTWORTH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6300
Practice Address - Country:US
Practice Address - Phone:773-548-8200
Practice Address - Fax:773-538-8683
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice