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General NPI Number Information
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NPI Number | 1831382134
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Entity Type | Organization
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Legal Business Name | NORTHEAST ORTHODONTIC ASSOCIATES. L.L.C.
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Dates
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Enumeration Date | 08/21/2007
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 25 5TH ST NE
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City | WATERTOWN
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State | SD
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Zip | 57201-3712
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Country | US
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Telephone | 605-882-1500
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Fax | 605-882-7090
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Provider Business Mailing Address
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Address Line | 25 5TH ST NE P O BOX 1450
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City | WATERTOWN
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State | SD
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Zip | 57201-3712
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Country | US
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Telephone | 605-882-1500
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Fax | 605-882-7090
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Authorized Official
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Title or Position | OWNER
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Name | DR. RYAN K VAN LAECKEN
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Credential | D.D.S., M.S.
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Telephone | 605-882-2772
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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 | M817
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License Number State | SD
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