Provider Demographics
NPI:1518295567
Name:VIRGINIA-GILBERT FAMILY DENTAL P.A
Entity Type:Organization
Organization Name:VIRGINIA-GILBERT FAMILY DENTAL P.A
Other - Org Name:ERICKSON HOLBECK DENTAL / GILBERT DENTAL SERVICE P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY - DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ZUPANCIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-741-0405
Mailing Address - Street 1:612-13TH. ST. SO.
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-741-0405
Mailing Address - Fax:218-741-1445
Practice Address - Street 1:612-13TH. ST. SO.
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-741-0405
Practice Address - Fax:218-741-1445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIRGINIA-GILBERT FAMILY DENTAL P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-03
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1058060070Medicare NSC