Provider Demographics
NPI:1790152197
Name:GENTLE DENTAL CENTER
Entity Type:Organization
Organization Name:GENTLE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYS
Authorized Official - Middle Name:VALCOURT
Authorized Official - Last Name:EWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MPH
Authorized Official - Phone:708-307-8844
Mailing Address - Street 1:2917 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-2729
Mailing Address - Country:US
Mailing Address - Phone:773-476-8217
Mailing Address - Fax:773-476-8251
Practice Address - Street 1:2917 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2729
Practice Address - Country:US
Practice Address - Phone:773-476-8217
Practice Address - Fax:773-476-8251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022941261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental