Provider Demographics
NPI:1366264772
Name:CHELSEA BROCKWAY DDS MS PLLC
Entity type:Organization
Organization Name:CHELSEA BROCKWAY DDS MS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-417-3958
Mailing Address - Street 1:10265 GANDY BLVD N APT 1615
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2335
Mailing Address - Country:US
Mailing Address - Phone:727-417-3958
Mailing Address - Fax:
Practice Address - Street 1:1527 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-2374
Practice Address - Country:US
Practice Address - Phone:727-250-0522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental