Provider Demographics
NPI:1720200108
Name:TWIN CITIES ORTHODONTIC SPECIALISTS
Entity Type:Organization
Organization Name:TWIN CITIES ORTHODONTIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-420-1030
Mailing Address - Street 1:7860 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7055
Mailing Address - Country:US
Mailing Address - Phone:763-420-1030
Mailing Address - Fax:763-420-5510
Practice Address - Street 1:7860 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7055
Practice Address - Country:US
Practice Address - Phone:763-420-1030
Practice Address - Fax:763-420-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7060302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization