Provider Demographics
NPI:1790493849
Name:THE GORMAN CENTER FOR FINE DEN
Entity Type:Organization
Organization Name:THE GORMAN CENTER FOR FINE DEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-703-0118
Mailing Address - Street 1:700 VILLAGE CENTER DRIVE
Mailing Address - Street 2:STE.,100
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3020
Mailing Address - Country:US
Mailing Address - Phone:651-483-5134
Mailing Address - Fax:
Practice Address - Street 1:700 VILLAGE CENTER DR
Practice Address - Street 2:STE 100
Practice Address - City:NORTH OAKS
Practice Address - State:MN
Practice Address - Zip Code:55127-5512
Practice Address - Country:US
Practice Address - Phone:651-483-5134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND14693OtherNPI