Provider Demographics
NPI:1508160060
Name:ORAL & MAXILLOFACIAL SURGERY SPECIALISTS, PA
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY SPECIALISTS, PA
Other - Org Name:OMS SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRBY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-788-9246
Mailing Address - Street 1:550 COUNTY ROAD D
Mailing Address - Street 2:SUITE 12
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-259-9902
Mailing Address - Fax:651-259-9930
Practice Address - Street 1:1595 2ND AVE NE STE 120
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-8071
Practice Address - Country:US
Practice Address - Phone:763-757-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU72794Medicare UPIN
MNU72187Medicare UPIN
MNT39145Medicare UPIN