Provider Demographics
NPI:1417142175
Name:IMAGINE ORTHODONTICS
Entity Type:Organization
Organization Name:IMAGINE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SOLTYS LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-802-4673
Mailing Address - Street 1:14096 STARLITE DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-5812
Mailing Address - Country:US
Mailing Address - Phone:763-428-1912
Mailing Address - Fax:
Practice Address - Street 1:14020 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9612
Practice Address - Country:US
Practice Address - Phone:763-428-1912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty