Provider Demographics
NPI:1780035378
Name:CHOAL, ILENE (DDS)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:CHOAL
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 1:417 W FLYING CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4701
Mailing Address - Country:US
Mailing Address - Phone:307-682-3353
Mailing Address - Fax:
Practice Address - Street 1:417 W FLYING CIRCLE DR
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4701
Practice Address - Country:US
Practice Address - Phone:307-682-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice