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Organization
SIRI CHANTHASALO, D.D.S., P.C.
Active
Organization
SIRI CHANTHASALO, D.D.S., P.C.
Active
Other names
Providence Family Dental
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SIRI CHANTHASALO D.D.S. (PRESIDENT)
(847) 217-7215
Entity
Organization
Contact information
Practice address
3091 W. ROUTE 20, #103, ELGIN, IL 60124
(847) 841-1555
Mailing address
452 WESTPORT DR, PINGREE GROVE, IL 60140-9172
(847) 217-7215
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019.025831
IL
Other
Enumeration date
10/08/2008
Last updated
10/08/2008
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