Provider Demographics
NPI:1457462228
Name:GAVIN, MICHAEL KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:GAVIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 LAKE MURRAY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1905
Mailing Address - Country:US
Mailing Address - Phone:604-285-8208
Mailing Address - Fax:619-462-4312
Practice Address - Street 1:5680 LAKE MURRAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1905
Practice Address - Country:US
Practice Address - Phone:858-208-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374201223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
450347443OtherFEDERALTAX ID NUMBER