1699901140 NPI number — NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699901140 NPI number — NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699901140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 GAMBLE DR
Provider Second Line Business Mailing Address:
SUITE 125
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-1585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-465-0105
Provider Business Mailing Address Fax Number:
952-465-0106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 GAMBLE DR
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-1585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-465-0105
Provider Business Practice Location Address Fax Number:
952-465-0106
Provider Enumeration Date:
06/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHAVEZ
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-465-0105

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  D11399 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CO5268 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DQ4459 . This is a "MEDICARE RAILROAD PTAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 187847 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3AI37NO . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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