Provider Demographics
NPI:1275859159
Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGY
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-281-5820
Mailing Address - Street 1:2717 SUPERIOR DR NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3035
Mailing Address - Country:US
Mailing Address - Phone:507-281-5820
Mailing Address - Fax:507-282-6543
Practice Address - Street 1:2717 SUPERIOR DR NW
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3035
Practice Address - Country:US
Practice Address - Phone:507-281-5820
Practice Address - Fax:507-282-6543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN857932600Medicaid
MN06D38MAOtherBLUE CROSS BLUE SHIELD
MN857932600Medicaid