Provider Demographics
NPI:1003983701
Name:MIDWEST ORAL & MAXILLOFACIAL SURGERY PA
Entity Type:Organization
Organization Name:MIDWEST ORAL & MAXILLOFACIAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:HUELER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-226-7940
Mailing Address - Street 1:13875 HWY 13 FRONTAGE RD
Mailing Address - Street 2:STE 50
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378
Mailing Address - Country:US
Mailing Address - Phone:952-226-7940
Mailing Address - Fax:952-226-7949
Practice Address - Street 1:13875 HWY 13 FRONTAGE RD
Practice Address - Street 2:STE 50
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378
Practice Address - Country:US
Practice Address - Phone:952-226-7940
Practice Address - Fax:952-226-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
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
U32115Medicare UPIN