Provider Demographics
NPI:1750343638
Name:GILLEN, STEVEN (DMD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:GILLEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:ROUTE 19
Practice Address - Street 2:NORTHGATE PLAZA
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301
Practice Address - Country:US
Practice Address - Phone:724-223-0750
Practice Address - Fax:724-223-8761
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014570640004Medicaid
PA0014570640014Medicaid
PA0014570640008Medicaid
PA0014570640009Medicaid
PA0014570640006Medicaid
PA0014570640021Medicaid
PA0014570640010Medicaid
PA0014570640020Medicaid
PA0014570640011Medicaid
PA0014570640019Medicaid
PA0014570640017Medicaid
PA0014570640016Medicaid
PA0014570640018Medicaid