Provider Demographics
NPI:1407179922
Name:UTA, GABRIEL (DDS)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:UTA
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 1:9194 W 159TH ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5648
Mailing Address - Country:US
Mailing Address - Phone:708-364-1880
Mailing Address - Fax:708-745-5109
Practice Address - Street 1:9194 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5648
Practice Address - Country:US
Practice Address - Phone:708-364-1880
Practice Address - Fax:708-745-5109
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist