Basic Information
| Provider Information | |||||||||
| NPI: | 1235429267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 FRANCE AVE S | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517700055 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Practice Location | |||||||||
| Address1: | 1714 COPE AVE E | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551092664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517700055 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEDNAR | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9522249771 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.