Provider Demographics
NPI:1427237551
Name:MIDTLING ORAL & MAXILLOFACIAL SURGERY, PA
Entity type:Organization
Organization Name:MIDTLING ORAL & MAXILLOFACIAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:I
Authorized Official - Last Name:MIDTLING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-222-6396
Mailing Address - Street 1:155 WABASHA ST S
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1801
Mailing Address - Country:US
Mailing Address - Phone:651-222-6396
Mailing Address - Fax:651-215-3189
Practice Address - Street 1:155 WABASHA ST S
Practice Address - Street 2:SUITE 111
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1801
Practice Address - Country:US
Practice Address - Phone:651-222-6396
Practice Address - Fax:651-215-3189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10555261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery