Provider Demographics
NPI:1508416017
Name:GAVINO, MITCHEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:
Last Name:GAVINO
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 1:1501 E 10TH ST STE 213
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-1936
Mailing Address - Country:US
Mailing Address - Phone:612-968-3576
Mailing Address - Fax:
Practice Address - Street 1:1501 E 10TH ST STE 213
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:612-968-3576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09710122300000X
MND15011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist