Provider Demographics
NPI:1134286057
Name:CHANTHASALO, SIRI (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIRI
Middle Name:
Last Name:CHANTHASALO
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 1:452 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9172
Mailing Address - Country:US
Mailing Address - Phone:847-217-7215
Mailing Address - Fax:
Practice Address - Street 1:3091 W. ROUTE 20
Practice Address - Street 2:#103
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124
Practice Address - Country:US
Practice Address - Phone:847-841-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0258311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice