Provider Demographics
NPI:1073988796
Name:CHEVANCE, GABRIELLE (DMD)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:CHEVANCE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4213
Mailing Address - Country:US
Mailing Address - Phone:815-398-3879
Mailing Address - Fax:815-398-1085
Practice Address - Street 1:1110 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4213
Practice Address - Country:US
Practice Address - Phone:815-398-3879
Practice Address - Fax:815-398-1085
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist