1699901140 NPI number — NORTHERN STAR ORAL AND MAXILLOFACIAL SURGERY PLLC

Table of content: (NPI 1699901140)

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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