Provider Demographics
NPI:1114178183
Name:SIRI CHANTHASALO, D.D.S., P.C.
Entity type:Organization
Organization Name:SIRI CHANTHASALO, D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANTHASALO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-217-7215
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0258311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty