Provider Demographics
NPI:1023452638
Name:FOREST LAKE ORTHODONTICS
Entity type:Organization
Organization Name:FOREST LAKE ORTHODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:651-464-1151
Mailing Address - Street 1:25 LAKE ST N
Mailing Address - Street 2:SUITE 135
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2535
Mailing Address - Country:US
Mailing Address - Phone:651-464-1151
Mailing Address - Fax:651-464-0620
Practice Address - Street 1:25 LAKE ST N
Practice Address - Street 2:SUITE 135
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2535
Practice Address - Country:US
Practice Address - Phone:651-464-1151
Practice Address - Fax:651-464-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty