Healthcare Provider Details

I. General information

NPI: 1588465702
Provider Name (Legal Business Name): SAMANTHA E GILLOOLEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17519 80TH AVE
TINLEY PARK IL
60477-4300
US

IV. Provider business mailing address

12340 W BENTWOOD DR
HOMER GLEN IL
60491-6971
US

V. Phone/Fax

Practice location:
  • Phone: 708-578-6692
  • Fax:
Mailing address:
  • Phone: 708-927-3959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.036108
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: