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General NPI Number Information
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NPI Number | 1669828539
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Entity Type | Organization
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Legal Business Name | NORTHSTAR ORTHODONTICS, INC.
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Dates
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Enumeration Date | 05/10/2016
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Last Update Date | 05/10/2016
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Provider Practice Location Address
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Address Line | 218 INDUSTRIAL PARK RD
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City | PARK RAPIDS
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State | MN
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Zip | 56470-3508
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Country | US
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Telephone | 218-732-9503
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Fax |
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Provider Business Mailing Address
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Address Line | 218 INDUSTRIAL PARK RD
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City | PARK RAPIDS
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State | MN
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Zip | 56470-3508
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Country | US
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Telephone | 218-732-9503
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Fax |
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Authorized Official
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Title or Position | CEO/CFO
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Name | MRS. CYNTHIA J. KELLY
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Credential |
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Telephone | 218-732-9503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 292200000X
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Taxonomy Name | Dental Laboratory
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License Number | DL109
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License Number State | MN
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