=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578505152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNESOTA ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 09/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 WOODBURY DR
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55129-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-714-4987
-----------------------------------------------------
Fax | 651-730-0415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 WOODBURY DR
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55129-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-450-7273
-----------------------------------------------------
Fax | 507-645-1684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | REGINA L BLEVINS
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 651-714-4987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 10244
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------