Healthcare Provider Details

I. General information

NPI: 1013199561
Provider Name (Legal Business Name): FAMILY & COSMETIC GENTLE DENTISTRY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 SUBURBAN AVE
SAINT PAUL MN
55106-6632
US

IV. Provider business mailing address

6600 FRANCE AVE S #415
EDINA MN
55435-1805
US

V. Phone/Fax

Practice location:
  • Phone: 651-209-3139
  • Fax: 651-209-3138
Mailing address:
  • Phone: 952-224-9771
  • Fax: 952-224-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DIANA GAVIC
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 952-224-9771