Provider Demographics
NPI:1073026514
Name:BUCHAL, GINA MARIE (ADT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:BUCHAL
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SHORELINE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-4527
Mailing Address - Country:US
Mailing Address - Phone:952-224-9775
Mailing Address - Fax:952-224-9774
Practice Address - Street 1:5001 WINNETKA AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4230
Practice Address - Country:US
Practice Address - Phone:763-533-0055
Practice Address - Fax:763-533-0057
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT52125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist