Healthcare Provider Details

I. General information

NPI: 1063974780
Provider Name (Legal Business Name): ODONTOTECH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 BLACKSHIRE PATH
INVER GROVE HEIGHTS MN
55076-1620
US

IV. Provider business mailing address

5870 BLACKSHIRE PATH
INVER GROVE HEIGHTS MN
55076-1620
US

V. Phone/Fax

Practice location:
  • Phone: 651-433-7200
  • Fax: 651-760-4333
Mailing address:
  • Phone: 651-433-7200
  • Fax: 651-760-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. VLADIMIR LEON
Title or Position: ORTHODONTIST
Credential: DDS, MSD
Phone: 651-433-7200