Provider Demographics
NPI:1386723575
Name:CENTRAL LAKES ORAL & FACIAL SURGERY
Entity type:Organization
Organization Name:CENTRAL LAKES ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:VAN SURKSUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-257-9555
Mailing Address - Street 1:2380 TROOP DRIVE
Mailing Address - Street 2:STE 202
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-257-9555
Mailing Address - Fax:320-257-9558
Practice Address - Street 1:2380 TROOP DRIVE
Practice Address - Street 2:STE 202
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-257-9555
Practice Address - Fax:320-257-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A65221025048OtherPREFERRED
8600574OtherMEDICA