Provider Demographics
NPI:1104249259
Name:CAMPODONICO FAMILY & COSMETIC DENTISTRY PC
Entity type:Organization
Organization Name:CAMPODONICO FAMILY & COSMETIC DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:CAMPODONICO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-786-1545
Mailing Address - Street 1:11806 ABERDEEN ST NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4736
Mailing Address - Country:US
Mailing Address - Phone:763-786-1545
Mailing Address - Fax:763-786-2939
Practice Address - Street 1:11806 ABERDEEN ST NE
Practice Address - Street 2:SUITE 150
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4736
Practice Address - Country:US
Practice Address - Phone:763-786-1545
Practice Address - Fax:763-786-2939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1154546877OtherNPI