Provider Demographics
NPI:1972766798
Name:BRODERSEN, GAY WINIFRED (DDS)
Entity Type:Individual
Prefix:DR
First Name:GAY
Middle Name:WINIFRED
Last Name:BRODERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1880 N ROSELLE RD
Practice Address - Street 2:STE.212
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195-3197
Practice Address - Country:US
Practice Address - Phone:847-882-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.023646122300000X
IL021.0017491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI421529687Medicare PIN