Healthcare Provider Details

I. General information

NPI: 1639370174
Provider Name (Legal Business Name): ORTHOGNATHIC SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 UNIVERSITY AVE SE STE 101
MINNEAPOLIS MN
55414-3231
US

IV. Provider business mailing address

2701 UNIVERSITY AVE SE STE 101
MINNEAPOLIS MN
55414-3231
US

V. Phone/Fax

Practice location:
  • Phone: 612-379-2424
  • Fax:
Mailing address:
  • Phone: 612-379-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberD7060
License Number StateMN

VIII. Authorized Official

Name: JER HUNT
Title or Position: OFFICE MANAGER
Credential:
Phone: 612-379-2424