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General NPI Number Information
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NPI Number | 1730517954
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Entity Type | Organization
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Legal Business Name | BRAINERD AREA ORTHODONTICS, LLC
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Dates
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Enumeration Date | 10/25/2013
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Last Update Date | 11/13/2014
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Provider Practice Location Address
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Address Line | 13367 ISLE DR SUITE 2
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City | BAXTER
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State | MN
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Zip | 56425-2221
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Country | US
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Telephone | 218-838-2650
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Fax | 218-454-2672
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Provider Business Mailing Address
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Address Line | 13367 ISLE DR SUITE 2
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City | BAXTER
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State | MN
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Zip | 56425-2221
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Country | US
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Telephone | 218-838-2650
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Fax | 218-454-2672
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPHEN WILLIAM COLBY
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Credential | DDS, MS, PA
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Telephone | 218-838-2650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13161
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10906
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License Number State | MN
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