Provider Demographics
NPI:1831382134
Name:NORTHEAST ORTHODONTIC ASSOCIATES. L.L.C.
Entity type:Organization
Organization Name:NORTHEAST ORTHODONTIC ASSOCIATES. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAN LAECKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:605-882-2772
Mailing Address - Street 1:25 5TH ST NE
Mailing Address - Street 2:P O BOX 1450
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-3712
Mailing Address - Country:US
Mailing Address - Phone:605-882-1500
Mailing Address - Fax:605-882-7090
Practice Address - Street 1:25 5TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3712
Practice Address - Country:US
Practice Address - Phone:605-882-1500
Practice Address - Fax:605-882-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty