Healthcare Provider Details

I. General information

NPI: 1356496350
Provider Name (Legal Business Name): GENRIKH GANDELSMAN DDS MSD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 FALLING WATERS BLVD
LINDENHURST IL
60046-6793
US

IV. Provider business mailing address

3065 FALLING WATERS BLVD
LINDENHURST IL
60046-6793
US

V. Phone/Fax

Practice location:
  • Phone: 224-643-4381
  • Fax:
Mailing address:
  • Phone: 224-643-4381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. GENRIKH GANDELSMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 224-643-4381