MEDICARE: FAMILY & COSMETIC GENTLE DENTISTRY, LTD

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295917755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY & COSMETIC GENTLE DENTISTRY, LTD

Provider Business Mailing Address
First Line	:	6600 FRANCE AVE S STE 415
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1817
Country	:	US
Telephone Number	:	952-224-9771
Fax Number	:	952-224-9790

Provider Business Practice Location Address
First Line	:	5401 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-2443
Country	:	US
Telephone Number	:	612-827-2801
Fax Number	:	612-827-7097

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	DIANA GAVIC
Credential	:
Telephone Number	:	952-224-9771

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	06/20/2008

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