Provider Demographics
NPI:1891114096
Name:GIGANTI DENTAL
Entity Type:Organization
Organization Name:GIGANTI DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:THEOHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-839-2824
Mailing Address - Street 1:317 ELMGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-2036
Mailing Address - Country:US
Mailing Address - Phone:314-839-2824
Mailing Address - Fax:
Practice Address - Street 1:317 ELMGROVE AVE
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2036
Practice Address - Country:US
Practice Address - Phone:314-839-2824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110270461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty