Healthcare Provider Details

I. General information

NPI: 1790795821
Provider Name (Legal Business Name): GREAT LAKES CHILDRENS DENTAL CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PIEDMONT AVENUE
DULUTH MN
55811
US

IV. Provider business mailing address

2710 PIEDMONT AVENUE
DULUTH MN
55811
US

V. Phone/Fax

Practice location:
  • Phone: 218-525-5100
  • Fax: 218-722-3883
Mailing address:
  • Phone: 218-525-5100
  • Fax: 218-722-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD10919
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD11559
License Number StateMN

VIII. Authorized Official

Name: DR. RAMI M GUIRGUIS
Title or Position: OWNER
Credential: DDS MS
Phone: 218-525-5100