1962449850 NPI number — GATES DENTAL CARE PC

Table of content: (NPI 1962449850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962449850 NPI number — GATES DENTAL CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATES DENTAL CARE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ORALUS
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962449850
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8135 N MILWAUKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60714-2828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-967-1149
Provider Business Mailing Address Fax Number:
847-967-8594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 E SAINT CHARLES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VILLA PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60181-2420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-836-4410
Provider Business Practice Location Address Fax Number:
630-563-9174
Provider Enumeration Date:
06/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAGUIB
Authorized Official First Name:
GAMAL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-967-1149

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  019014756 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33060 . This is a "BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 019014756 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".