Provider Demographics
NPI:1093011132
Name:GORMAN, PATRICK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:GORMAN
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 1:615 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2329
Mailing Address - Country:US
Mailing Address - Phone:708-331-1900
Mailing Address - Fax:708-331-1248
Practice Address - Street 1:615 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2329
Practice Address - Country:US
Practice Address - Phone:708-331-1900
Practice Address - Fax:708-331-1248
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A145671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice