Provider Demographics
NPI:1770762866
Name:GASTON, TRACEY L (DDS)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:L
Last Name:GASTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:GASTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:9901 S WESTERN AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1800
Mailing Address - Country:US
Mailing Address - Phone:773-233-1710
Mailing Address - Fax:773-233-1704
Practice Address - Street 1:9901 S WESTERN AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1800
Practice Address - Country:US
Practice Address - Phone:773-233-1710
Practice Address - Fax:773-233-1704
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice