Provider Demographics
NPI:1508058322
Name:GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:RICHARD W BRUNTON PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-351-1010
Mailing Address - Street 1:2850 CURVE CREST BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-351-1010
Mailing Address - Fax:651-351-9333
Practice Address - Street 1:2850 CURVE CREST BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-351-1010
Practice Address - Fax:651-351-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33714200OtherMEDICAL ASSISTANCE
MNCC02769Medicaid
MN616822100OtherMEDICAL ASSISTANCE
MN88A90BROtherBLUE CROSS BLUE SHIELD
WI000079110Medicare PIN