Provider Demographics
NPI:1124198635
Name:A GENTLE DENTAL CENTER OF ROGERS
Entity Type:Organization
Organization Name:A GENTLE DENTAL CENTER OF ROGERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:PUCEL
Authorized Official - Last Name:KOOPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-428-2226
Mailing Address - Street 1:14115 JAMES RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9468
Mailing Address - Country:US
Mailing Address - Phone:763-428-2226
Mailing Address - Fax:763-428-3407
Practice Address - Street 1:14115 JAMES RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9468
Practice Address - Country:US
Practice Address - Phone:763-428-2226
Practice Address - Fax:763-428-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND116661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty