Provider Demographics
NPI:1356496350
Name:GENRIKH GANDELSMAN DDS MSD LTD
Entity Type:Organization
Organization Name:GENRIKH GANDELSMAN DDS MSD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENRIKH
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDELSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:224-643-4381
Mailing Address - Street 1:3065 FALLING WATERS BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6793
Mailing Address - Country:US
Mailing Address - Phone:224-643-4381
Mailing Address - Fax:
Practice Address - Street 1:3065 FALLING WATERS BLVD
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-6793
Practice Address - Country:US
Practice Address - Phone:224-643-4381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty