Provider Demographics
NPI:1417175696
Name:MINNESOTA ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS PA
Entity Type:Organization
Organization Name:MINNESOTA ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS PA
Other - Org Name:NORTHFIELD ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL COORD
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-750-7273
Mailing Address - Street 1:2019 JEFFERSON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3258
Mailing Address - Country:US
Mailing Address - Phone:507-333-2990
Mailing Address - Fax:507-645-1684
Practice Address - Street 1:2019 JEFFERSON RD
Practice Address - Street 2:SUITE C
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3258
Practice Address - Country:US
Practice Address - Phone:507-333-2990
Practice Address - Fax:507-645-1684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty