Provider Demographics
NPI:1497890594
Name:MICHAEL K SUTLEY DDS PA
Entity Type:Organization
Organization Name:MICHAEL K SUTLEY DDS PA
Other - Org Name:MINNEAPOLIS ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SUTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-333-3381
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 707 MEDICAL ARTS BUILDING
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-333-3381
Mailing Address - Fax:612-334-3318
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 707 MEDICAL ARTS BUILDING
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-333-3381
Practice Address - Fax:612-334-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND90861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41426OROtherBLUE CROSS BLUE SHIELD
MN8080107OtherMEDICA MEDICAL
MN01007972OtherPREFERRED ONE
MN8622286OtherMEDICA DENTAL