Healthcare Provider Details

I. General information

NPI: 1447265970
Provider Name (Legal Business Name): GSDC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 W IRVING PARK RD
CHICAGO IL
60618-3210
US

IV. Provider business mailing address

3524 W IRVING PARK RD
CHICAGO IL
60618-3210
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-4650
  • Fax: 773-588-4631
Mailing address:
  • Phone: 773-588-4650
  • Fax: 773-588-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CHARISMA LUAT
Title or Position: DENTIST
Credential: DDS
Phone: 773-588-4650