Provider Demographics
NPI:1811108970
Name:GOTTLIEB, SEYMOUR LEO (DDS)
Entity type:Individual
Prefix:DR
First Name:SEYMOUR
Middle Name:LEO
Last Name:GOTTLIEB
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 1:806 CENTRAL AVE
Mailing Address - Street 2:SUITE201
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-5613
Mailing Address - Country:US
Mailing Address - Phone:847-266-0565
Mailing Address - Fax:847-835-2445
Practice Address - Street 1:806 CENTRAL AVE
Practice Address - Street 2:SUITE201
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-5613
Practice Address - Country:US
Practice Address - Phone:847-266-0565
Practice Address - Fax:847-835-2445
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019113251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice