Provider Demographics
NPI:1114689114
Name:WILLETT, CHANTEL
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:
Last Name:WILLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANTEL
Other - Middle Name:
Other - Last Name:FAULKENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23W423 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-9599
Mailing Address - Country:US
Mailing Address - Phone:708-979-1511
Mailing Address - Fax:
Practice Address - Street 1:300 E 5TH AVE STE 420
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3403
Practice Address - Country:US
Practice Address - Phone:630-369-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020015121124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist