Provider Demographics
NPI:1164803177
Name:FAMILY AND COSMETIC GENTLE DENTISTRY
Entity Type:Organization
Organization Name:FAMILY AND COSMETIC GENTLE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:BODIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-224-9774
Mailing Address - Street 1:4100 SHORELINE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-4508
Mailing Address - Country:US
Mailing Address - Phone:952-224-9774
Mailing Address - Fax:952-224-9791
Practice Address - Street 1:1421 WAYZATA BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1939
Practice Address - Country:US
Practice Address - Phone:952-224-9774
Practice Address - Fax:952-224-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1952399685Medicaid