Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DEN4391 | ME |
Y | 1223E0200X | Endodontist | 19032497 | IL |
NPI | 1003223660 |
---|---|
Provider Name | Jenna Gaw |
First Address | Schaumburg, IL 60173-4239 |
Second Address | Schaumburg, IL 60173-4836 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2014 |
Last Update Date | 19/10/2020 |