MEDICARE: DR. KENT C GULDEN D.D.S. P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6967	MN

General Provider Information

NPI Number	:	1124123328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENT C GULDEN D.D.S. P.A.

Provider Business Mailing Address
First Line	:	4437 LAKE AVE S
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3455
Country	:	US
Telephone Number	:	651-429-5265
Fax Number	:	651-429-9630

Provider Business Practice Location Address
First Line	:	4437 LAKE AVE S
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3455
Country	:	US
Telephone Number	:	651-429-5265
Fax Number	:	651-429-9630

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	09/03/2008

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