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General NPI Number Information
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NPI Number | 1972766798
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Entity Type | Individual
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Provider Name | GAY WINIFRED BRODERSEN D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 09/24/2008
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Provider Practice Location Address
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Address Line | 1880 N ROSELLE RD STE.212
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City | SCHAUMBURG
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State | IL
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Zip | 60195-3197
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Country | US
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Telephone | 847-882-3360
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Fax |
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Provider Business Mailing Address
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Address Line | 212 N GRANT ST
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City | HINSDALE
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State | IL
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Zip | 60521-3336
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.023646
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 021.001749
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License Number State | IL
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