1104160480 NPI number — MINNESOTA CRANIOFACIAL CENTER P.C.

Table of content: (NPI 1104160480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104160480 NPI number — MINNESOTA CRANIOFACIAL CENTER P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA CRANIOFACIAL CENTER P.C.
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:
1104160480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
SUITE 143N
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-642-1013
Provider Business Mailing Address Fax Number:
651-642-0947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE 143N
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-642-1013
Provider Business Practice Location Address Fax Number:
651-642-0947
Provider Enumeration Date:
11/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEDERMANN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
651-642-1013

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  11715 , 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)





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