Provider Demographics
NPI:1023659315
Name:GJELLUM, CHELCIE (RDH, CSOM)
Entity type:Individual
Prefix:
First Name:CHELCIE
Middle Name:
Last Name:GJELLUM
Suffix:
Gender:F
Credentials:RDH, CSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10342 ROWLOCK WAY
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9577
Mailing Address - Country:US
Mailing Address - Phone:719-588-1748
Mailing Address - Fax:
Practice Address - Street 1:9105 KIMMER DR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-8454
Practice Address - Country:US
Practice Address - Phone:303-799-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH000906352124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist