Provider Demographics
NPI:1760837041
Name:FAMILY AND COSMETIC GENTLE DENTISTRY
Entity Type:Organization
Organization Name:FAMILY AND COSMETIC GENTLE DENTISTRY
Other - Org Name:FAMILY AND COSMETIC GENTLE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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 1:5107 GUS YOUNG LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1530
Mailing Address - Country:US
Mailing Address - Phone:952-929-0641
Mailing Address - Fax:952-929-1802
Practice Address - Street 1:5107 GUS YOUNG LN
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-1530
Practice Address - Country:US
Practice Address - Phone:952-929-0641
Practice Address - Fax:952-929-1802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FMAILY AND COSMETIC GENTLE DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty