Provider Demographics
NPI:1093997546
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:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-224-9771
Mailing Address - Street 1:6600 FRANCE AVE S STE 415
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1817
Mailing Address - Country:US
Mailing Address - Phone:952-224-9771
Mailing Address - Fax:952-224-9790
Practice Address - Street 1:1340 DUCKWOOD DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2324
Practice Address - Country:US
Practice Address - Phone:651-209-9999
Practice Address - Fax:651-209-0396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY & COSMETIC GENTLE DENTISTRY, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-27
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN625193500Medicaid