Healthcare Provider Details

I. General information

NPI: 1295284701
Provider Name (Legal Business Name): HENSELER ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 CURVE CREST BLVD W
STILLWATER MN
55082-4039
US

IV. Provider business mailing address

2850 CURVE CREST BLVD W
STILLWATER MN
55082-4039
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8909
  • Fax:
Mailing address:
  • Phone: 651-439-8909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD12265
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10804
License Number StateMN

VIII. Authorized Official

Name: STEVEN JOHN HENSELER
Title or Position: DDS ORTHODONTIST
Credential: DDS, PA
Phone: 651-439-8909