Healthcare Provider Details

I. General information

NPI: 1700934882
Provider Name (Legal Business Name): KUIPERS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 W 4TH ST
RED WING MN
55066-2413
US

IV. Provider business mailing address

615 W 4TH ST
RED WING MN
55066-2413
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-8851
  • Fax: 651-388-5572
Mailing address:
  • Phone: 651-388-8851
  • Fax: 651-388-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7434
License Number StateMN

VIII. Authorized Official

Name: PETER W KUIPERS
Title or Position: OWNER
Credential: DDS PHD
Phone: 651-388-8851