Provider Demographics
NPI:1265650956
Name:ORAL AND MAXILLOFACIAL SURGICAL CONSULTANTS PA
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGICAL CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KECKHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-841-9658
Mailing Address - Street 1:250 CENTRAL AVE N
Mailing Address - Street 2:SUITE126
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1206
Mailing Address - Country:US
Mailing Address - Phone:952-475-2266
Mailing Address - Fax:952-475-0637
Practice Address - Street 1:250 CENTRAL AVE N
Practice Address - Street 2:SUITE126
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1206
Practice Address - Country:US
Practice Address - Phone:952-475-2266
Practice Address - Fax:952-475-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty