Provider Demographics
NPI:1932370160
Name:G & A DENTAL PC
Entity Type:Organization
Organization Name:G & A DENTAL PC
Other - Org Name:GAMMA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-465-4500
Mailing Address - Street 1:P.O. BOX 564
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044
Mailing Address - Country:US
Mailing Address - Phone:773-465-4500
Mailing Address - Fax:773-353-2102
Practice Address - Street 1:1514 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-465-4500
Practice Address - Fax:773-353-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-15
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
IL0600097361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty