Provider Demographics
NPI:1639677735
Name:EVOLVE ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:EVOLVE ORTHODONTICS PLLC
Other - Org Name:EVOLVE ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DITCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-804-4028
Mailing Address - Street 1:41625 BUR OAK HILLS RD
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-7448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 22ND AVE E STE 702
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4653
Practice Address - Country:US
Practice Address - Phone:612-804-4028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND136501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty