Provider Demographics
NPI:1932782703
Name:HAAS, CHRISTOPHER JOHN
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:HAAS
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 1:3 WIMBLEDON CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3146
Mailing Address - Country:US
Mailing Address - Phone:618-978-3522
Mailing Address - Fax:
Practice Address - Street 1:4945 STONE FALLS CTR STE B
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7801
Practice Address - Country:US
Practice Address - Phone:618-622-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0340441223P0221X
IL019.0340441223P0221X
390200000X
IL0190340441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program