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General NPI Number Information
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NPI Number | 1144656059
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Entity Type | Organization
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Legal Business Name | BURNSVILLE ORTHODONTIC ASSOCIATES PLLC
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Dates
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Enumeration Date | 09/24/2013
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Last Update Date | 11/10/2015
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Provider Practice Location Address
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Address Line | 625 E NICOLLET BLVD SUITE 300
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City | BURNSVILLE
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State | MN
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Zip | 55337-6734
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Country | US
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Telephone | 952-435-0350
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Fax | 952-435-0325
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Provider Business Mailing Address
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Address Line | 625 E NICOLLET BLVD SUITE 300
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City | BURNSVILLE
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State | MN
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Zip | 55337-6734
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Country | US
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Telephone | 952-435-0350
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Fax | 952-435-0325
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LILAH SUZAN EKIM
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Credential | D.D.S., M.S.
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Telephone | 952-435-0350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12091
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12008
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License Number State | MN
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