Provider Demographics
NPI:1851502033
Name:GASTON, DAVID LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:GASTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 GRAND AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2458
Mailing Address - Country:US
Mailing Address - Phone:847-249-0046
Mailing Address - Fax:
Practice Address - Street 1:2634 GRAND AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2458
Practice Address - Country:US
Practice Address - Phone:847-249-0046
Practice Address - Fax:847-249-1035
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0183201223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics