Provider Demographics
NPI:1407019516
Name:DANIELS, DAN GERALD (DDS)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:GERALD
Last Name:DANIELS
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 1:938 E ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-3927
Mailing Address - Country:US
Mailing Address - Phone:630-231-2442
Mailing Address - Fax:630-231-8544
Practice Address - Street 1:938 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-3927
Practice Address - Country:US
Practice Address - Phone:630-231-2442
Practice Address - Fax:630-231-8544
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190202841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice