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General NPI Number Information
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NPI Number | 1710442413
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Entity Type | Organization
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Legal Business Name | SMILES IN MOTION OF MINNESOTA PC
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Dates
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Enumeration Date | 02/06/2019
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 2480 WHITE BEAR AVE N
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City | MAPLEWOOD
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State | MN
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Zip | 55109-5121
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Country | US
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Telephone | 651-777-8182
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Fax |
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Provider Business Mailing Address
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Address Line | 3902 OAKWOOD HILLS PKWY
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City | EAU CLAIRE
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State | WI
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Zip | 54701-7780
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Country | US
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Telephone | 651-777-8182
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEVEN KRISTO
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Credential | DDS, MS
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Telephone | 651-777-8182
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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 |
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License Number State |
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