Provider Demographics
NPI:1003093485
Name:LAKEVILLE ORTHODONTIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:LAKEVILLE ORTHODONTIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOWLBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-435-4000
Mailing Address - Street 1:10440 185TH ST W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6678
Mailing Address - Country:US
Mailing Address - Phone:952-435-4000
Mailing Address - Fax:952-435-8001
Practice Address - Street 1:10440 185TH ST W
Practice Address - Street 2:SUITE 300
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6678
Practice Address - Country:US
Practice Address - Phone:952-435-4000
Practice Address - Fax:952-435-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty