Provider Demographics
NPI:1588296024
Name:GAUTAM, ABHINA (MS)
Entity type:Individual
Prefix:DR
First Name:ABHINA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E GRANT ST APT 1706
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1476
Mailing Address - Country:US
Mailing Address - Phone:352-214-4330
Mailing Address - Fax:
Practice Address - Street 1:2680 E SNELLING SER DR
Practice Address - Street 2:100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:612-662-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDPRM20961223P0700X
MNS2151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics