Healthcare Provider Details

I. General information

NPI: 1609434570
Provider Name (Legal Business Name): JORDAN TAYLOR GABRIELE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

1001 S GEORGE ST
YORK PA
17403-3676
US

V. Phone/Fax

Practice location:
  • Phone: 173-833-3112
  • Fax:
Mailing address:
  • Phone: 717-851-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number018.002180
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: