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General NPI Number Information
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NPI Number | 1124244603
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Entity Type | Organization
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Legal Business Name | CAMBRIDGE ORTHODONTICS PA
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 140 BIRCH ST N #106
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City | CAMBRIDGE
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State | MN
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Zip | 55008
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Country | US
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Telephone | 763-689-3134
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Fax | 763-689-6609
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Provider Business Mailing Address
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Address Line | 140 BIRCH ST N #106
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City | CAMBRIDGE
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State | MN
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Zip | 55008
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Country | US
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Telephone | 763-689-3134
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Fax | 763-689-6609
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Authorized Official
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Title or Position | 100 PERCENT SHAREHOLDER OF S CORP
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Name | BRADLEY L VIDEEN
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Credential | DDS MS
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Telephone | 763-689-3134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8936
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License Number State | MN
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