Provider Demographics
NPI:1841210267
Name:CHASE, JUSTINE KONANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:KONANE
Last Name:CHASE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JUSTINE
Other - Middle Name:KONANE
Other - Last Name:VIAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4579 HWY 20 E SUITE 210
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-897-4200
Mailing Address - Fax:850-897-4504
Practice Address - Street 1:4579 HWY 20 E SUITE 210
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-897-4200
Practice Address - Fax:850-897-4504
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-14797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist