Provider Demographics
NPI:1700940343
Name:LAKE MINNETONKA ORTHDONTICS
Entity Type:Organization
Organization Name:LAKE MINNETONKA ORTHDONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:952-933-8444
Mailing Address - Street 1:11601 MINNETONKA MILLS RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11601 MINNETONKA MILLS RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5161
Practice Address - Country:US
Practice Address - Phone:952-938-1443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN70941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty