Provider Demographics
NPI:1740427954
Name:RUSSELL H GERTSCH DDS, PC
Entity Type:Organization
Organization Name:RUSSELL H GERTSCH DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:HAYWARD
Authorized Official - Last Name:GERTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-748-8181
Mailing Address - Street 1:4343 SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1254
Mailing Address - Country:US
Mailing Address - Phone:708-748-8181
Mailing Address - Fax:708-748-6002
Practice Address - Street 1:4343 SAUK TRL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1254
Practice Address - Country:US
Practice Address - Phone:708-748-8181
Practice Address - Fax:708-748-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0159251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-015925OtherSTATE OF ILLINOIS DENTAL LICENSE