Provider Demographics
NPI:1609250620
Name:WEST & EHLIS ORTHODONTIC MANAGEMENT COMPANY LLC
Entity Type:Organization
Organization Name:WEST & EHLIS ORTHODONTIC MANAGEMENT COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-293-5300
Mailing Address - Street 1:4710 AMBER VALLEY PKWY S
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8694
Mailing Address - Country:US
Mailing Address - Phone:701-293-5300
Mailing Address - Fax:701-293-3317
Practice Address - Street 1:4710 AMBER VALLEY PKWY S
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8694
Practice Address - Country:US
Practice Address - Phone:701-293-5300
Practice Address - Fax:701-293-3317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty