Provider Demographics
NPI:1730526229
Name:SIM, GABRIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:SIM
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 1:2551 N CLARK ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1798
Mailing Address - Country:US
Mailing Address - Phone:773-871-2161
Mailing Address - Fax:
Practice Address - Street 1:2551 N CLARK ST
Practice Address - Street 2:SUITE 404
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1798
Practice Address - Country:US
Practice Address - Phone:773-871-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.024019122300000X
IL021.0019241223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist