Provider Demographics
NPI:1053865865
Name:MISCH, GINA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:MISCH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 W 60TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-3313
Mailing Address - Country:US
Mailing Address - Phone:312-206-9480
Mailing Address - Fax:
Practice Address - Street 1:6535 W 60TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-3313
Practice Address - Country:US
Practice Address - Phone:312-206-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020-007937124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist