Basic Information
Provider Information | |||||||||
NPI: | 1013199561 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6600 FRANCE AVE S | ||||||||
Address2: | #415 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554351805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9522249771 | ||||||||
FaxNumber: | 9522249790 | ||||||||
Practice Location | |||||||||
Address1: | 1680 SUBURBAN AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551066632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512093139 | ||||||||
FaxNumber: | 6512093138 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2007 | ||||||||
LastUpdateDate: | 06/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAVIC | ||||||||
AuthorizedOfficialFirstName: | DIANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9522249771 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 997903100 | 05 | MN |   | MEDICAID |