Provider Demographics
NPI:1649324146
Name:GERHARDT, DELORA EILEEN (RDH)
Entity type:Individual
Prefix:
First Name:DELORA
Middle Name:EILEEN
Last Name:GERHARDT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-0172
Mailing Address - Country:US
Mailing Address - Phone:815-653-9573
Mailing Address - Fax:
Practice Address - Street 1:7424 HANCOCK DR
Practice Address - Street 2:
Practice Address - City:WONDER LAKE
Practice Address - State:IL
Practice Address - Zip Code:60097-9217
Practice Address - Country:US
Practice Address - Phone:815-653-5141
Practice Address - Fax:815-653-3191
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist