=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790152197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENTLE DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 09/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2917 W 63RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-476-8217
-----------------------------------------------------
Fax | 773-476-8251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2917 W 63RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-476-8217
-----------------------------------------------------
Fax | 773-476-8251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARILYS VALCOURT EWA
-----------------------------------------------------
Credential | DDS,MPH
-----------------------------------------------------
Telephone | 708-307-8844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019022941
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------