Provider Demographics
NPI:1578157848
Name:YOUR ORTHO LLC
Entity Type:Organization
Organization Name:YOUR ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-481-6726
Mailing Address - Street 1:1735 OAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-8658
Mailing Address - Country:US
Mailing Address - Phone:301-481-6726
Mailing Address - Fax:
Practice Address - Street 1:2236 LOGAN BLVD N STE 502
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-1490
Practice Address - Country:US
Practice Address - Phone:301-481-6726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty