Provider Demographics
NPI:1164980322
Name:VIALL, CHRISTOPHER LUKE
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LUKE
Last Name:VIALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 SHADOW LN STE 101
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1120
Mailing Address - Country:US
Mailing Address - Phone:952-448-4151
Mailing Address - Fax:
Practice Address - Street 1:2634 SHADOW LN STE 101
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1120
Practice Address - Country:US
Practice Address - Phone:952-448-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND149951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice