Healthcare Provider Details

I. General information

NPI: 1669817557
Provider Name (Legal Business Name): ORTHODONTIC CARE SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 SAINT ANTHONY AVE
SAINT PAUL MN
55104-4005
US

IV. Provider business mailing address

14605 GLAZIER AVE
APPLE VALLEY MN
55124-7545
US

V. Phone/Fax

Practice location:
  • Phone: 651-286-8153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1223X0400X
License Number StateMN

VIII. Authorized Official

Name: MS. KARIE THERESE GRADEN
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 952-432-1103