Provider Demographics
NPI:1477112456
Name:FAMILY & COSMETIC GENTLE DENTISTRY, LTD
Entity Type:Organization
Organization Name:FAMILY & COSMETIC GENTLE DENTISTRY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
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:952-224-9788
Mailing Address - Street 1:2147 NORTHDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:651-209-3139
Mailing Address - Fax:
Practice Address - Street 1:2147 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:651-209-3139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN256415000Medicaid