Healthcare Provider Details

I. General information

NPI: 1699267633
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF MINNESOTA, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HAZELTINE BLVD
CHASKA MN
55318
US

IV. Provider business mailing address

2200 COUNTY ROAD C W STE 2210
ROSEVILLE MN
55113-2551
US

V. Phone/Fax

Practice location:
  • Phone: 952-241-5860
  • Fax:
Mailing address:
  • Phone: 651-746-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOHN GULON
Title or Position: PRESIDENT
Credential: DDS
Phone: 651-746-2815