Basic Information
| Provider Information | |||||||||
| NPI: | 1982886859 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 85TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554336022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522249771 | ||||||||
| FaxNumber: | 9522249790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | GAVIC | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9522249771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY & COSMETIC GENTLE DENTISTRY, LTD | ||||||||
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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 | 783105000 | 05 | MN | MEDICAID |