=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306404389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLE COE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2019
-----------------------------------------------------
Last Update Date | 06/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 S RACE ST
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61723-7586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-648-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 445
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61723-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-648-2828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.032148
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------