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General NPI Number Information
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NPI Number | 1538219746
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Entity Type | Organization
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Legal Business Name | ORTHODONTIC SPECIALISTS
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 20174 HERITAGE DRIVE LAKEVILLE
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City | LAKEVILLE
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State | MN
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Zip | 55044
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Country | US
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Telephone | 952-469-6760
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Fax | 952-469-3254
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Provider Business Mailing Address
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Address Line | 20174 HERITAGE DRIVE LAKEVILLE
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City | LAKEVILLE
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State | MN
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Zip | 55044
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Country | US
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Telephone | 952-469-6760
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Fax | 952-469-3254
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. JEANNE MARCIA GAU
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Credential | DDS MS
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Telephone | 952-469-6760
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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 | MN9323
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License Number State | MN
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