Provider Demographics
NPI:1306188305
Name:GURNEE ORTHODONTICS LLC
Entity Type:Organization
Organization Name:GURNEE ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:847-249-1000
Mailing Address - Street 1:30 N SLUSSER ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3662
Mailing Address - Country:US
Mailing Address - Phone:847-249-1000
Mailing Address - Fax:847-249-1001
Practice Address - Street 1:101 S GREENLEAF ST
Practice Address - Street 2:UNIT E
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3369
Practice Address - Country:US
Practice Address - Phone:847-249-1000
Practice Address - Fax:847-249-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210007861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty