Provider Demographics
NPI:1992146757
Name:GERSHENZON, DAVID B (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:GERSHENZON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 904
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-372-8538
Mailing Address - Fax:312-372-0607
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 904
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-372-8538
Practice Address - Fax:312-372-0607
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.29507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist