Basic Information
| Provider Information | |||||||||
| NPI: | 1831360973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVALDON | ||||||||
| FirstName: | IRMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E 5TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485021641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104064912 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | G-3375 S. SAGINAW ST. | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107436830 | ||||||||
| FaxNumber: | 8107437102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901019338 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 382406558 | 01 | MI | TAX ID | OTHER |