Healthcare Provider Details

I. General information

NPI: 1720200108
Provider Name (Legal Business Name): TWIN CITIES ORTHODONTIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7860 MAIN ST
MAPLE GROVE MN
55369-7055
US

IV. Provider business mailing address

7860 MAIN ST
MAPLE GROVE MN
55369-7055
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-1030
  • Fax: 763-420-5510
Mailing address:
  • Phone: 763-420-1030
  • Fax: 763-420-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number7060
License Number StateMN

VIII. Authorized Official

Name: MRS. CAROLYN JOHNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 763-420-1030