Provider Demographics
NPI:1366676553
Name:AFFILIATED ORAL AND MAXILLOFACIAL SURGEONS P.A.
Entity Type:Organization
Organization Name:AFFILIATED ORAL AND MAXILLOFACIAL SURGEONS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-474-6336
Mailing Address - Street 1:348 2ND ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1830
Mailing Address - Country:US
Mailing Address - Phone:952-474-6336
Mailing Address - Fax:952-474-2468
Practice Address - Street 1:348 2ND ST
Practice Address - Street 2:SUITE 150
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-1830
Practice Address - Country:US
Practice Address - Phone:952-474-6336
Practice Address - Fax:952-474-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN315223500Medicaid
MN352518000Medicaid
MN190000247Medicare PIN
MNT39824Medicare UPIN
MN315223500Medicaid
MN190000514Medicare PIN