Provider Demographics
NPI:1851997498
Name:FOSTER, GINA L (BS RDH PHDH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:FOSTER
Suffix:
Gender:F
Credentials:BS RDH PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 THEODORE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-6019
Mailing Address - Country:US
Mailing Address - Phone:217-778-9336
Mailing Address - Fax:
Practice Address - Street 1:1111 THEODORE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-6019
Practice Address - Country:US
Practice Address - Phone:217-778-9336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.012599124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist