Provider Demographics
NPI:1447506571
Name:GERALD D. CAVANAUGH & WILLIAM F. LILJEMARK
Entity type:Organization
Organization Name:GERALD D. CAVANAUGH & WILLIAM F. LILJEMARK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BOWLBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-926-2335
Mailing Address - Street 1:3939 W. 50TH ST
Mailing Address - Street 2:SUITE #207
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1258
Mailing Address - Country:US
Mailing Address - Phone:952-926-2335
Mailing Address - Fax:952-925-0467
Practice Address - Street 1:3939 W. 50TH ST
Practice Address - Street 2:SUITE #207
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1258
Practice Address - Country:US
Practice Address - Phone:952-926-2335
Practice Address - Fax:952-925-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11240,9023,10908AND1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty