Provider Demographics
NPI:1730288242
Name:GATEWAY DENTAL CENTRE, P.C.
Entity Type:Organization
Organization Name:GATEWAY DENTAL CENTRE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-876-9200
Mailing Address - Street 1:534 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-2843
Mailing Address - Country:US
Mailing Address - Phone:630-876-9200
Mailing Address - Fax:630-876-9201
Practice Address - Street 1:534 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-2843
Practice Address - Country:US
Practice Address - Phone:630-876-9200
Practice Address - Fax:630-876-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9176645Medicaid