Provider Demographics
NPI:1760683171
Name:CHARNOTA, GWEN MAY (DDS)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:MAY
Last Name:CHARNOTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706
Mailing Address - Country:US
Mailing Address - Phone:708-453-1313
Mailing Address - Fax:
Practice Address - Street 1:7821 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706
Practice Address - Country:US
Practice Address - Phone:708-453-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist