Provider Demographics
NPI:1427563386
Name:MINNESOTA OPHTHALMIC PLASTIC SURGERY SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:MINNESOTA OPHTHALMIC PLASTIC SURGERY SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-925-4161
Mailing Address - Street 1:6405 FRANCE AVE S STE W460
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2189
Mailing Address - Country:US
Mailing Address - Phone:952-925-4161
Mailing Address - Fax:952-925-3520
Practice Address - Street 1:6405 FRANCE AVE S STE W460
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2189
Practice Address - Country:US
Practice Address - Phone:952-925-4161
Practice Address - Fax:952-925-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33370207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty