Provider Demographics
NPI:1083394704
Name:AIDASANI, GAURAV
Entity Type:Individual
Prefix:
First Name:GAURAV
Middle Name:
Last Name:AIDASANI
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 1:2 E ERIE ST APT 3512
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3161
Mailing Address - Country:US
Mailing Address - Phone:310-351-2918
Mailing Address - Fax:
Practice Address - Street 1:4721 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-3001
Practice Address - Country:US
Practice Address - Phone:773-847-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0345501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice