NPIMap

Organization Active NPI

Family and Cosmetic Gentle Dentistry

  • General Practice Dentistry
  • Wayzata, MN
National Provider Identifier
1164803177
Registry record updated Jun 16, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
FAMILY AND COSMETIC GENTLE DENTISTRY
Practice address
1421 Wayzata Blvd
Suite 320
Wayzata, MN 55391-1939
Phone
(952) 224-9774
Fax
(952) 224-9791
NPI assigned
Jun 16, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Robert Luther Bodin, DDS
Title
Dentist
Phone
(952) 224-9774

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

1421 Wayzata Blvd
Suite 320
Wayzata, MN 55391-1939

Mailing address

4100 Shoreline Dr
Suite 4
Spring Park, MN 55384-4508
Phone (952) 224-9774

Other identifiers 1

IdentifierTypeStateIssuer
1952399685MedicaidMN

National Provider Directory

National Provider Directory
Tax ID family
Family Cosmetic Gentle Dentistry LTD16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

Organizations that report the same tax identification number in the National Provider Directory.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1434412800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1434412800000",
    "number": "1164803177",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4100 SHORELINE DR",
            "address_2": "SUITE 4",
            "city": "SPRING PARK",
            "state": "MN",
            "postal_code": "553844508",
            "telephone_number": "952-224-9774",
            "fax_number": "952-224-9791"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1421 WAYZATA BLVD",
            "address_2": "SUITE 320",
            "city": "WAYZATA",
            "state": "MN",
            "postal_code": "553911939",
            "telephone_number": "952-224-9774",
            "fax_number": "952-224-9791"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY AND COSMETIC GENTLE DENTISTRY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-16",
        "last_updated": "2015-06-16",
        "status": "A",
        "authorized_official_last_name": "BODIN",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "LUTHER",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "952-224-9774",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1952399685",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wayzata, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.