Provider Demographics
NPI:1801360383
Name:MISCHLICH, GINA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:MISCHLICH
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 1:307 MILLSTREAM TER
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-4217
Mailing Address - Country:US
Mailing Address - Phone:719-229-0747
Mailing Address - Fax:
Practice Address - Street 1:835 E PLATTE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3547
Practice Address - Country:US
Practice Address - Phone:719-229-0747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000904991124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist