Provider Demographics
NPI:1568527166
Name:GAVINO, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
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 1:2500 HIGHWAY 88
Mailing Address - Street 2:NORTHGATE OFFICE PARK, SUITE 115
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4223
Mailing Address - Country:US
Mailing Address - Phone:612-789-1373
Mailing Address - Fax:612-789-1373
Practice Address - Street 1:2500 HIGHWAY 88
Practice Address - Street 2:NORTHGATE OFFICE PARK, SUITE 115
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4223
Practice Address - Country:US
Practice Address - Phone:612-789-1373
Practice Address - Fax:612-789-1373
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist