Provider Demographics
NPI:1831581693
Name:COMMEDORE, CHANELLE
Entity type:Individual
Prefix:DR
First Name:CHANELLE
Middle Name:
Last Name:COMMEDORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271386
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-1386
Mailing Address - Country:US
Mailing Address - Phone:813-540-0313
Mailing Address - Fax:
Practice Address - Street 1:20042 EVA ST STE 100
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-2042
Practice Address - Country:US
Practice Address - Phone:936-206-7069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX319091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice