Provider Demographics
NPI:1083357727
Name:FAMILY ORTHODONTIC SPECIALISTS, PLC
Entity Type:Organization
Organization Name:FAMILY ORTHODONTIC SPECIALISTS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:13784 83RD WAY N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7192
Mailing Address - Country:US
Mailing Address - Phone:763-494-6612
Mailing Address - Fax:
Practice Address - Street 1:13784 83RD WAY N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7192
Practice Address - Country:US
Practice Address - Phone:763-494-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY ORTHODONTIC SPECIALISTS, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty