Provider Demographics
NPI:1053567156
Name:VIDA, GABRIEL ERNEST (DDS)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ERNEST
Last Name:VIDA
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 1:3855 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4640
Mailing Address - Country:US
Mailing Address - Phone:773-782-8900
Mailing Address - Fax:773-782-0577
Practice Address - Street 1:3855 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4640
Practice Address - Country:US
Practice Address - Phone:773-782-8900
Practice Address - Fax:773-782-0577
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020849122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist