Provider Demographics
NPI:1194101055
Name:BRUCE MARTINSON FAMILY & COSMETIC DENTISTRY
Entity type:Organization
Organization Name:BRUCE MARTINSON FAMILY & COSMETIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-473-4639
Mailing Address - Street 1:317 E WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-473-4639
Mailing Address - Fax:952-473-1788
Practice Address - Street 1:317 E WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-473-4639
Practice Address - Fax:952-473-1788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND93011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty