Provider Demographics
NPI:1871932236
Name:CHANTELOIS, CASEY ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:CASEY
Middle Name:ALAN
Last Name:CHANTELOIS
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 1:1449 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6707
Mailing Address - Country:US
Mailing Address - Phone:715-222-1354
Mailing Address - Fax:
Practice Address - Street 1:1340 DUCKWOOD DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2324
Practice Address - Country:US
Practice Address - Phone:651-209-9999
Practice Address - Fax:651-209-0396
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND132771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice