Healthcare Provider Details

I. General information

NPI: 1730517954
Provider Name (Legal Business Name): BRAINERD AREA ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13367 ISLE DR SUITE 2
BAXTER MN
56425-2221
US

IV. Provider business mailing address

13367 ISLE DR SUITE 2
BAXTER MN
56425-2221
US

V. Phone/Fax

Practice location:
  • Phone: 218-838-2650
  • Fax: 218-454-2672
Mailing address:
  • Phone: 218-838-2650
  • Fax: 218-454-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13161
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10906
License Number StateMN

VIII. Authorized Official

Name: DR. STEPHEN WILLIAM COLBY
Title or Position: OWNER
Credential: DDS, MS, PA
Phone: 218-838-2650