Healthcare Provider Details

I. General information

NPI: 1003093485
Provider Name (Legal Business Name): LAKEVILLE ORTHODONTIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10440 185TH ST W SUITE 300
LAKEVILLE MN
55044-6678
US

IV. Provider business mailing address

10440 185TH ST W SUITE 300
LAKEVILLE MN
55044-6678
US

V. Phone/Fax

Practice location:
  • Phone: 952-435-4000
  • Fax: 952-435-8001
Mailing address:
  • Phone: 952-435-4000
  • Fax: 952-435-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD12240
License Number StateMN

VIII. Authorized Official

Name: DR. SCOTT R BOWLBY
Title or Position: DOCTOR
Credential: D.D.S.
Phone: 952-435-4000