Provider Demographics
NPI:1710442413
Name:SMILES IN MOTION OF MINNESOTA PC
Entity Type:Organization
Organization Name:SMILES IN MOTION OF MINNESOTA PC
Other - Org Name:GREAT RIVER ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-777-8182
Mailing Address - Street 1:3902 OAKWOOD HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7780
Mailing Address - Country:US
Mailing Address - Phone:651-777-8182
Mailing Address - Fax:
Practice Address - Street 1:2480 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5121
Practice Address - Country:US
Practice Address - Phone:651-777-8182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty