Provider Demographics
NPI: | 1710344494 |
---|---|
Name: | BLOOMINGTON SMILES DENTISTRY, PC |
Entity Type: | Organization |
Organization Name: | BLOOMINGTON SMILES DENTISTRY, PC |
Other - Org Name: | BLOOMINGTON SMILES DENITSTRY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | PAUL |
Authorized Official - Middle Name: | S |
Authorized Official - Last Name: | GEBHART |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 952-679-3531 |
Mailing Address - Street 1: | 17000 RED HILL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | IRVINE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92614-5626 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-845-8890 |
Mailing Address - Fax: | 949-474-1495 |
Practice Address - Street 1: | 10700 FRANCE AVENUE |
Practice Address - Street 2: | SUITE 102 |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55437 |
Practice Address - Country: | US |
Practice Address - Phone: | 952-679-3531 |
Practice Address - Fax: | 952-232-0484 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-01-26 |
Last Update Date: | 2016-01-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |