Basic Information
| Provider Information | |||||||||
| NPI: | 1023414174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY AND COSMETIC GENTLE DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 SHORELINE DR | ||||||||
| Address2: | #4 | ||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553844508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522249783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 42ND AVE N | ||||||||
| Address2: | |||||||||
| City: | NEW HOPE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554271225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2014 | ||||||||
| LastUpdateDate: | 11/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | BODIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LUTHER | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9522249783 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.