MEDICARE: DR. GARY M FINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8158	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	008653	OTHER	MN	DORAL
2	008128	OTHER	MN	DORAL

General Provider Information

NPI Number	:	1023007713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY M FINE

Provider Business Mailing Address
First Line	:	825 NICOLLET MALL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2606
Country	:	US
Telephone Number	:	612-332-1336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. GARY M FINE ” Practice Location

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