Healthcare Provider Details

I. General information

NPI: 1245393230
Provider Name (Legal Business Name): LAKES ORTHODONTIC ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 COPE AVE E
MAPLEWOOD MN
55109-2655
US

IV. Provider business mailing address

1668 COPE AVE E
MAPLEWOOD MN
55109-2655
US

V. Phone/Fax

Practice location:
  • Phone: 651-777-7300
  • Fax: 651-777-9131
Mailing address:
  • Phone: 651-777-7300
  • Fax: 651-777-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9462
License Number StateMN

VIII. Authorized Official

Name: DR. KEVIN LEE DENIS
Title or Position: CEO
Credential: DDS, MS
Phone: 651-777-7300