Provider Demographics
NPI:1477871457
Name:INSTITUTE OF FACIAL SURGERY ST PAUL, PLLC
Entity Type:Organization
Organization Name:INSTITUTE OF FACIAL SURGERY ST PAUL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:BRUNSOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-774-9611
Mailing Address - Street 1:1774 COPE AVE E
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2662
Mailing Address - Country:US
Mailing Address - Phone:651-774-9611
Mailing Address - Fax:651-748-3704
Practice Address - Street 1:1774 COPE AVE E
Practice Address - Street 2:SUITE 140
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2662
Practice Address - Country:US
Practice Address - Phone:651-774-9611
Practice Address - Fax:651-748-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-14
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND6950261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental