Basic Information
| Provider Information | |||||||||
| NPI: | 1952399685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 FRANCE AVE S STE 415 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554351817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522249771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5100 EDEN AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554362338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529290641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 10/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | BODIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LUTHER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9522249771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0700X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.