Provider Demographics
NPI:1497404818
Name:FAMILY ORAL SURGERY SPECIALISTS, PLC
Entity Type:Organization
Organization Name:FAMILY ORAL SURGERY SPECIALISTS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:15785 95TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4404
Mailing Address - Country:US
Mailing Address - Phone:763-233-4141
Mailing Address - Fax:763-420-3158
Practice Address - Street 1:15785 95TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4404
Practice Address - Country:US
Practice Address - Phone:763-233-4141
Practice Address - Fax:763-420-3158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY ORAL SURGERY SPECIALISTS, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty