Provider Demographics
NPI:1174600621
Name:INTERLACHEN DENTAL ASSOCIATES
Entity type:Organization
Organization Name:INTERLACHEN DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-920-9579
Mailing Address - Street 1:5101 VERNON AVENUE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436
Mailing Address - Country:US
Mailing Address - Phone:952-920-9579
Mailing Address - Fax:952-920-9298
Practice Address - Street 1:5101 VERNON AVENUE
Practice Address - Street 2:SUITE 1B
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436
Practice Address - Country:US
Practice Address - Phone:952-920-9579
Practice Address - Fax:952-920-9298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty