Provider Demographics
NPI:1114169224
Name:KING ORTHODONTICS, LTD
Entity Type:Organization
Organization Name:KING ORTHODONTICS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-424-3632
Mailing Address - Street 1:1575 20TH ST NW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2930
Mailing Address - Country:US
Mailing Address - Phone:507-332-0022
Mailing Address - Fax:507-333-9553
Practice Address - Street 1:3000 43RD ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5847
Practice Address - Country:US
Practice Address - Phone:507-424-3632
Practice Address - Fax:507-281-8757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KING ORTHODONTICS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-03
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11171261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN719448000Medicaid