MEDICARE: WHITE BEAR LAKE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730782467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE BEAR LAKE ORTHODONTICS

Provider Business Mailing Address
First Line	:	4437 LAKE AVE S
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3455
Country	:	US
Telephone Number	:	763-999-0055
Fax Number	:

Provider Business Practice Location Address
First Line	:	4437 LAKE AVE S
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3455
Country	:	US
Telephone Number	:	763-999-0055
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ORTHODONTIST
Name	:	TAMARA SMITH
Credential	:	DDS, MSD
Telephone Number	:	763-999-0055

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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Directions to “WHITE BEAR LAKE ORTHODONTICS ” Practice Location

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