MEDICARE: ORCHARD DENTAL GROUP, P.L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D9611	MN

General Provider Information

NPI Number	:	1932335098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORCHARD DENTAL GROUP, P.L.L.C.

Provider Business Mailing Address
First Line	:	12 LONG LAKE RD # 12
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-6814
Country	:	US
Telephone Number	:	651-770-2699
Fax Number	:	651-770-9896

Provider Business Practice Location Address
First Line	:	12 LONG LAKE RD # 12
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-6814
Country	:	US
Telephone Number	:	651-770-2699
Fax Number	:	651-770-9896

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. ROBERT J MAROLT
Credential	:	D.D.S.
Telephone Number	:	651-770-2699

Provider Enumeration Date	:	06/03/2009
Last Update Date	:	06/03/2009

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