Provider Demographics
NPI:1124067970
Name:VANTASELL, STEPHEN CRAIG (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CRAIG
Last Name:VANTASELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 W ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3471
Mailing Address - Country:US
Mailing Address - Phone:641-472-3158
Mailing Address - Fax:641-469-5111
Practice Address - Street 1:51 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-3471
Practice Address - Country:US
Practice Address - Phone:641-472-3158
Practice Address - Fax:641-469-5111
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA58021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0119917Medicaid