Provider Demographics
NPI:1376658674
Name:MICHAEL J GONDA DDS LTD
Entity Type:Organization
Organization Name:MICHAEL J GONDA DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GONDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-968-5078
Mailing Address - Street 1:4745 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532
Mailing Address - Country:US
Mailing Address - Phone:630-968-5078
Mailing Address - Fax:630-968-3621
Practice Address - Street 1:4745 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532
Practice Address - Country:US
Practice Address - Phone:630-968-5078
Practice Address - Fax:630-968-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty