Provider Demographics
NPI:1811128945
Name:GACKOWSKI, COLLEEN CHRISTINE (DDS)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:CHRISTINE
Last Name:GACKOWSKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:COLLEEN
Other - Middle Name:CHRISTINE
Other - Last Name:HICKLE-GACKOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3690 ORANGE PL
Mailing Address - Street 2:SUITE550
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4464
Mailing Address - Country:US
Mailing Address - Phone:216-464-0500
Mailing Address - Fax:216-464-0573
Practice Address - Street 1:3690 ORANGE PL
Practice Address - Street 2:SUITE 550
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4464
Practice Address - Country:US
Practice Address - Phone:216-464-0500
Practice Address - Fax:216-464-0573
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist