Provider Demographics
NPI:1578952065
Name:GERALD
Entity Type:Organization
Organization Name:GERALD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DISMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-902-8305
Mailing Address - Street 1:1016 MICHAELS LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3715
Mailing Address - Country:US
Mailing Address - Phone:847-902-8305
Mailing Address - Fax:
Practice Address - Street 1:1016 MICHAELS LN
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3715
Practice Address - Country:US
Practice Address - Phone:847-902-8305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019015751261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental