Healthcare Provider Details

I. General information

NPI: 1265535868
Provider Name (Legal Business Name): KOTTEMANN ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13998 MAPLE KNOLL WAY SUITE 102
MAPLE GROVE MN
55369-7004
US

IV. Provider business mailing address

13998 MAPLE KNOLL WAY SUITE 102
MAPLE GROVE MN
55369-7004
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-6834
  • Fax: 763-420-5642
Mailing address:
  • Phone: 763-420-6834
  • Fax: 763-420-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8583
License Number StateMN

VIII. Authorized Official

Name: DR. WILLIAM JOSEPH KOTTEMANN
Title or Position: OWNER
Credential: DDS
Phone: 763-420-6834