Provider Demographics
NPI:1275892218
Name:EDINA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:EDINA ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOMPACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-925-2525
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:SUITE 690
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-925-2525
Mailing Address - Fax:952-925-2529
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 690
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-925-2525
Practice Address - Fax:952-925-2529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND111281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty