Provider Demographics
NPI:1417042367
Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LAFLEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:218-722-1854
Mailing Address - Street 1:505 S 12TH AVE W STE 2
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2001
Mailing Address - Country:US
Mailing Address - Phone:218-741-0894
Mailing Address - Fax:218-741-4140
Practice Address - Street 1:505 S 12TH AVE W STE 2
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2001
Practice Address - Country:US
Practice Address - Phone:218-741-0894
Practice Address - Fax:218-741-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN208722700Medicaid
MN208722700Medicaid