Provider Demographics
NPI:1295218303
Name:ADVANCED ORAL SURGERY
Entity Type:Organization
Organization Name:ADVANCED ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCABE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:507-327-9574
Mailing Address - Street 1:19318 IMPALA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-1600
Mailing Address - Country:US
Mailing Address - Phone:507-327-9574
Mailing Address - Fax:
Practice Address - Street 1:19925 IDEALIC AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-2003
Practice Address - Country:US
Practice Address - Phone:507-327-9574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1023307113Medicaid