Provider Demographics
NPI:1134103674
Name:SOUTH SUBURBAN ORAL & MAXILLOFACIAL SURGEONS LTD
Entity Type:Organization
Organization Name:SOUTH SUBURBAN ORAL & MAXILLOFACIAL SURGEONS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PALMERSHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-435-0310
Mailing Address - Street 1:625 EAST NICOLLET BOULEVARD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6735
Mailing Address - Country:US
Mailing Address - Phone:952-435-0310
Mailing Address - Fax:952-435-0311
Practice Address - Street 1:625 EAST NICOLLET BOULEVARD
Practice Address - Street 2:SUITE 205
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6735
Practice Address - Country:US
Practice Address - Phone:952-435-0310
Practice Address - Fax:952-435-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
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
MN6B299PAOtherBCBS
MN6B299PAOtherBCBS