Provider Demographics
NPI:1427129717
Name:ST CROIX ORAL, MAXILLOFACIAL & IMPLANT SURGERY, P.A.
Entity type:Organization
Organization Name:ST CROIX ORAL, MAXILLOFACIAL & IMPLANT SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-439-8030
Mailing Address - Street 1:1701 CURVE CREST BLVD W
Mailing Address - Street 2:SUITE 108
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6044
Mailing Address - Country:US
Mailing Address - Phone:651-439-8030
Mailing Address - Fax:651-351-0821
Practice Address - Street 1:1701 CURVE CREST BLVD W
Practice Address - Street 2:SUITE 108
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6044
Practice Address - Country:US
Practice Address - Phone:651-439-8030
Practice Address - Fax:651-351-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty