Provider Demographics
NPI:1083372031
Name:OP ORTHODONTICS OF MINNESOTA PLLC
Entity Type:Organization
Organization Name:OP ORTHODONTICS OF MINNESOTA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-859-0444
Mailing Address - Street 1:250 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1737
Mailing Address - Country:US
Mailing Address - Phone:218-460-5417
Mailing Address - Fax:
Practice Address - Street 1:250 ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1737
Practice Address - Country:US
Practice Address - Phone:218-460-5417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty