Provider Demographics
NPI:1790795821
Name:GREAT LAKES CHILDRENS DENTAL CARE PA
Entity Type:Organization
Organization Name:GREAT LAKES CHILDRENS DENTAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUIRGUIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:218-525-5100
Mailing Address - Street 1:2710 PIEDMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-525-5100
Mailing Address - Fax:218-722-3883
Practice Address - Street 1:2710 PIEDMONT AVENUE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:218-525-5100
Practice Address - Fax:218-722-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115591223D0001X
MND109191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty