Provider Demographics
NPI:1699267633
Name:ORTHODONTIC SPECIALISTS OF MINNESOTA, P.L.L.C.
Entity type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF MINNESOTA, P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GULON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-746-2815
Mailing Address - Street 1:2200 COUNTY ROAD C W STE 2210
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2551
Mailing Address - Country:US
Mailing Address - Phone:651-746-2815
Mailing Address - Fax:
Practice Address - Street 1:1150 HAZELTINE BLVD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318
Practice Address - Country:US
Practice Address - Phone:952-241-5860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty