Provider Demographics
NPI:1861796013
Name:GERVICH, MOLLY REBECCA (DDS)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:REBECCA
Last Name:GERVICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444
Mailing Address - Country:US
Mailing Address - Phone:218-534-3141
Mailing Address - Fax:218-534-3949
Practice Address - Street 1:21343 ARCHIBALD ROAD
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444
Practice Address - Country:US
Practice Address - Phone:218-534-3141
Practice Address - Fax:218-534-3949
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6637-151223G0001X
IA086371223G0001X
MND13489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice