Healthcare Provider Details

I. General information

NPI: 1891829669
Provider Name (Legal Business Name): GLK ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 BROADWAY AVE S STE A
ROCHESTER MN
55904-7973
US

IV. Provider business mailing address

1705 BROADWAY AVE S STE A
ROCHESTER MN
55904-7960
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-4427
  • Fax: 507-288-8497
Mailing address:
  • Phone: 507-288-4427
  • Fax: 507-288-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JODI KUBALL
Title or Position: ADMIN & FINANCIAL COORDINATOR
Credential:
Phone: 507-281-3121