Healthcare Provider Details

I. General information

NPI: 1023414174
Provider Name (Legal Business Name): FAMILY AND COSMETIC GENTLE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 42ND AVE N
NEW HOPE MN
55427-1225
US

IV. Provider business mailing address

4100 SHORELINE DR #4
SPRING PARK MN
55384-4508
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-0055
  • Fax:
Mailing address:
  • Phone: 952-224-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LUTHER BODIN
Title or Position: CEO/OWNER
Credential: DDS
Phone: 952-224-9783