MEDICARE: CENTRAL MINNESOTA ORTHODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	S-9	MN
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8228	MN
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	11705	MN

General Provider Information

NPI Number	:	1306901814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MINNESOTA ORTHODONTICS

Provider Business Mailing Address
First Line	:	1500 NORTHWAY DR
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-4477
Country	:	US
Telephone Number	:	320-529-4889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 NORTHWAY DR
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-4477
Country	:	US
Telephone Number	:	320-529-4889
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MARY LYNN LANGSJOEN
Credential	:
Telephone Number	:	320-255-1111

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	08/22/2020

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