Provider Demographics
NPI:1790012847
Name:VIRGINIA/GILBERT FAMILY DENTAL
Entity Type:Organization
Organization Name:VIRGINIA/GILBERT FAMILY DENTAL
Other - Org Name:ERICKSON HOLBECK ZUPANCIC DENTAL/GILBERT DENTAL SERVICE P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-741-5357
Mailing Address - Street 1:P.O. BOX 608
Mailing Address - Street 2:VIRGINIA/GILBERT FAMILY DENTAL
Mailing Address - City:GILBERT
Mailing Address - State:MN
Mailing Address - Zip Code:55741
Mailing Address - Country:US
Mailing Address - Phone:218-741-5357
Mailing Address - Fax:218-741-5455
Practice Address - Street 1:12 NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:MN
Practice Address - Zip Code:55741
Practice Address - Country:US
Practice Address - Phone:218-741-5357
Practice Address - Fax:218-741-5455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIRGINIA/GILBERT FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10580600700OtherSTATE OF MINNESOTA