Provider Demographics
NPI:1417124686
Name:GONDA, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:GONDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 MAIN STREET
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 STREET
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
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist