=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285771923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERALD T MINICK DDS MS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 01/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6020 S GUN CLUB RD UNIT E1
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80016-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-277-5286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6020 S GUN CLUB RD SUITE E-1
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80016-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-627-6212
-----------------------------------------------------
Fax | 303-627-1725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GERALD T MINICK
-----------------------------------------------------
Credential | D.D,S, M.S.
-----------------------------------------------------
Telephone | 303-627-6212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 9273
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------