Provider Demographics
NPI:1285757864
Name:MINNESOTA CRANIOFACIAL CENTER MIDWAY, P.A.
Entity type:Organization
Organization Name:MINNESOTA CRANIOFACIAL CENTER MIDWAY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:HAKALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-642-1013
Mailing Address - Street 1:2550 UNIVERSITY AVENUE WEST
Mailing Address - Street 2:SUITE 143N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1098
Mailing Address - Country:US
Mailing Address - Phone:651-642-1013
Mailing Address - Fax:651-642-0947
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 143N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-642-1013
Practice Address - Fax:651-642-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6257230001Medicare NSC