MEDICARE: DR. GARY ALAN BOLMGREN D.D.S., M.S.

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	9129	MN

General Provider Information

NPI Number	:	1215157631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ALAN BOLMGREN D.D.S., M.S.

Provider Business Mailing Address
First Line	:	381 SOUTHDALE MEDICAL CENTER
Second Line	:	6545 FRANCE AVE. S.
City	:	EDINA
State	:	MN
Zip	:	55435-2121
Country	:	US
Telephone Number	:	952-926-7766
Fax Number	:	952-926-2037

Provider Business Practice Location Address
First Line	:	381 SOUTHDALE MEDICAL CENTER
Second Line	:	6545 FRANCE AVE. S.
City	:	EDINA
State	:	MN
Zip	:	55435-2121
Country	:	US
Telephone Number	:	952-926-7766
Fax Number	:	952-926-2037

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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