Provider Demographics
NPI:1912202805
Name:GANDELSMAN, GENRIKH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GENRIKH
Middle Name:
Last Name:GANDELSMAN
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 1:3065 FALLING WATERS BLVD
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6793
Mailing Address - Country:US
Mailing Address - Phone:224-643-4381
Mailing Address - Fax:
Practice Address - Street 1:3065 FALLING WATERS BLVD
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-6793
Practice Address - Country:US
Practice Address - Phone:224-643-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210018871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics