Provider Demographics
NPI:1023414174
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:CEO/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:952-224-9783
Mailing Address - Street 1:4100 SHORELINE DR
Mailing Address - Street 2:#4
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-4508
Mailing Address - Country:US
Mailing Address - Phone:952-224-9783
Mailing Address - Fax:
Practice Address - Street 1:7500 42ND AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1225
Practice Address - Country:US
Practice Address - Phone:763-533-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental