Healthcare Provider Details

I. General information

NPI: 1801991146
Provider Name (Legal Business Name): FAMILY ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5804 EXCELSIOR BLVD
ST LOUIS PARK MN
55416
US

IV. Provider business mailing address

5804 EXCELSIOR BLVD
ST LOUIS PARK MN
55416
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-7117
  • Fax: 952-927-8534
Mailing address:
  • Phone: 952-922-7117
  • Fax: 952-927-8534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9941
License Number StateMN

VIII. Authorized Official

Name: DR. ANGELA V ROSS
Title or Position: OWNER
Credential: DMD
Phone: 952-922-7117