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General NPI Number Information
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NPI Number | 1306188305
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Entity Type | Organization
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Legal Business Name | GURNEE ORTHODONTICS LLC
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Dates
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Enumeration Date | 03/18/2013
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Last Update Date | 03/18/2013
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Provider Practice Location Address
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Address Line | 101 S GREENLEAF ST UNIT E
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City | GURNEE
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State | IL
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Zip | 60031-3369
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Country | US
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Telephone | 847-249-1000
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Fax | 847-249-1001
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Provider Business Mailing Address
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Address Line | 30 N SLUSSER ST
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City | GRAYSLAKE
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State | IL
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Zip | 60030-3662
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Country | US
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Telephone | 847-249-1000
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Fax | 847-249-1001
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TERRY SELLKE
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Credential | DDS MS
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Telephone | 847-249-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 021000786
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License Number State | IL
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