Provider Demographics
NPI:1003453515
Name:OMNI FACIAL PLASTIC SURGERY
Entity Type:Organization
Organization Name:OMNI FACIAL PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:ROLFES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-774-2411
Mailing Address - Street 1:935 WAYZATA BLVD E STE 200
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2513
Mailing Address - Country:US
Mailing Address - Phone:320-559-4500
Mailing Address - Fax:
Practice Address - Street 1:935 WAYZATA BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-2513
Practice Address - Country:US
Practice Address - Phone:320-559-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2018OtherCLA