Provider Demographics
NPI:1215096862
Name:GERLACH, AMELIA MIKKONEN (DDS)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:MIKKONEN
Last Name:GERLACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMELIA
Other - Middle Name:
Other - Last Name:MIKKONEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5809 91ST CRES N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1620
Mailing Address - Country:US
Mailing Address - Phone:763-424-7292
Mailing Address - Fax:
Practice Address - Street 1:6437 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2174
Practice Address - Country:US
Practice Address - Phone:763-531-7177
Practice Address - Fax:763-535-6284
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND116531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1643800Medicaid