Provider Demographics
NPI:1033501457
Name:GERWATOWSKI, LINDA
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:
Last Name:GERWATOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 BIG VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1018
Mailing Address - Country:US
Mailing Address - Phone:719-593-1203
Mailing Address - Fax:
Practice Address - Street 1:1445 BIG VALLEY DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1018
Practice Address - Country:US
Practice Address - Phone:719-593-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-22
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1038124Q00000X
MI2902002429124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist