Provider Demographics
NPI:1891442174
Name:GREAT RIVER ORTHODONTIC SPECIALISTS, SC
Entity Type:Organization
Organization Name:GREAT RIVER ORTHODONTIC SPECIALISTS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNTS MGR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-598-7473
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:
Mailing Address - Fax:
Practice Address - Street 1:2215 VINE ST STE B
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-5862
Practice Address - Country:US
Practice Address - Phone:715-808-8379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty