1508058322 NPI number — GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.

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 1508058322 NPI number — GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
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:
6
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:
1508058322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 CURVE CREST BLVD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-351-1010
Provider Business Mailing Address Fax Number:
651-351-9333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 CURVE CREST BLVD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-351-1010
Provider Business Practice Location Address Fax Number:
651-351-9333
Provider Enumeration Date:
08/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
651-351-1010

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  10762 , 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: 33714200 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: CC02769 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 616822100 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 88A90BR . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com