Provider Demographics
NPI:1437601283
Name:GATEWAY DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:GATEWAY DENTAL GROUP, LLC
Other - Org Name:TROY FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOATMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-667-8070
Mailing Address - Street 1:606 EDWARDSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294
Mailing Address - Country:US
Mailing Address - Phone:618-667-8020
Mailing Address - Fax:618-667-8078
Practice Address - Street 1:606 EDWARDSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294
Practice Address - Country:US
Practice Address - Phone:618-667-8020
Practice Address - Fax:618-667-8078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0209381223G0001X
IL19-0256361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty