Basic Information
Provider Information
NPI: 1073026514
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BUCHAL
FirstName: GINA
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential: ADT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4100 SHORELINE DR STE 4
Address2:  
City: SPRING PARK
State: MN
PostalCode: 553844527
CountryCode: US
TelephoneNumber: 9522249775
FaxNumber: 9522249774
Practice Location
Address1: 5001 WINNETKA AVE N
Address2:  
City: NEW HOPE
State: MN
PostalCode: 554284230
CountryCode: US
TelephoneNumber: 7635330055
FaxNumber: 7635330057
Other Information
ProviderEnumerationDate: 11/07/2017
LastUpdateDate: 11/07/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
125J00000XDT52MNY Dental ProvidersDental Therapist 

No ID Information.


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