Provider Demographics
NPI:1659424232
Name:WILLOUGHBY, STEWART GORDON (DDS LDS RCS MS)
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:GORDON
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:DDS LDS RCS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 S BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2656
Mailing Address - Country:US
Mailing Address - Phone:773-375-6199
Mailing Address - Fax:
Practice Address - Street 1:8301 S BRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2656
Practice Address - Country:US
Practice Address - Phone:773-375-6199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist