Provider Demographics
NPI:1306901814
Name:CENTRAL MINNESOTA ORTHODONTICS
Entity type:Organization
Organization Name:CENTRAL MINNESOTA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LANGSJOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-1111
Mailing Address - Street 1:1500 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4477
Mailing Address - Country:US
Mailing Address - Phone:320-529-4889
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4477
Practice Address - Country:US
Practice Address - Phone:320-529-4889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS-91223X0400X
MN82281223X0400X
MN117051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty