1790012847 NPI number — VIRGINIA/GILBERT FAMILY DENTAL

Table of content: (NPI 1790012847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790012847 NPI number — VIRGINIA/GILBERT FAMILY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA/GILBERT FAMILY DENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ERICKSON HOLBECK ZUPANCIC DENTAL/GILBERT DENTAL SERVICE P.A.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790012847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 608
Provider Second Line Business Mailing Address:
VIRGINIA/GILBERT FAMILY DENTAL
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-741-5357
Provider Business Mailing Address Fax Number:
218-741-5455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 NORTH BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-741-5357
Provider Business Practice Location Address Fax Number:
218-741-5455
Provider Enumeration Date:
11/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-741-5357

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10580600700 . This is a "STATE OF MINNESOTA" identifier . This identifiers is of the category "OTHER".




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