Provider Demographics
NPI:1659407112
Name:GUNVALSON, CATHY JO (RDH)
Entity Type:Individual
Prefix:MRS
First Name:CATHY JO
Middle Name:
Last Name:GUNVALSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14740 500TH ST
Mailing Address - Street 2:
Mailing Address - City:GONVICK
Mailing Address - State:MN
Mailing Address - Zip Code:56644-4173
Mailing Address - Country:US
Mailing Address - Phone:218-679-0125
Mailing Address - Fax:218-679-3990
Practice Address - Street 1:HWY 1 AND LAKE ST
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56644
Practice Address - Country:US
Practice Address - Phone:218-679-3316
Practice Address - Fax:218-679-3990
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3033124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist