Basic Information
| Provider Information | |||||||||
| NPI: | 1831382134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST ORTHODONTIC ASSOCIATES. L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 5TH ST NE | ||||||||
| Address2: | P O BOX 1450 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572013712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058821500 | ||||||||
| FaxNumber: | 6058827090 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572013712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058821500 | ||||||||
| FaxNumber: | 6058827090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | VAN LAECKEN | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6058822772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S., M.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | M817 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.