Provider Demographics
NPI:1194878959
Name:GNIADEK, BRIAN C (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:GNIADEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 E GRAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9094
Mailing Address - Country:US
Mailing Address - Phone:847-265-9070
Mailing Address - Fax:847-265-9279
Practice Address - Street 1:2031 E GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9094
Practice Address - Country:US
Practice Address - Phone:847-265-9070
Practice Address - Fax:847-265-9279
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0225581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-4247595OtherTAX ID
IL784607OtherUCCI PROVIDER #