Provider Demographics
NPI:1467751990
Name:GATEWAY FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:GATEWAY FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHUOP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-905-0035
Mailing Address - Street 1:7 JOSLIN LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01172-2647
Mailing Address - Country:US
Mailing Address - Phone:978-905-0035
Mailing Address - Fax:
Practice Address - Street 1:151 WARREN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2647
Practice Address - Country:US
Practice Address - Phone:978-905-0035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN201541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty