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General NPI Number Information
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NPI Number | 1700940343
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Entity Type | Organization
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Legal Business Name | LAKE MINNETONKA ORTHDONTICS
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11601 MINNETONKA MILLS RD
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City | MINNETONKA
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State | MN
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Zip | 55305-5161
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Country | US
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Telephone | 952-938-1443
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Fax |
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Provider Business Mailing Address
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Address Line | 11601 MINNETONKA MILLS RD
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City | MINNETONKA
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State | MN
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Zip | 55305-5161
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ACCOUNTANT
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Name | MS. DAWN J RENNER
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Credential | CPA
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Telephone | 952-933-8444
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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 | 7094
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License Number State | MN
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