Provider Demographics
NPI:1578596177
Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:URBAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:507-625-9330
Mailing Address - Street 1:1990 PREMIERE DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5900
Mailing Address - Country:US
Mailing Address - Phone:507-625-9330
Mailing Address - Fax:507-625-1440
Practice Address - Street 1:1990 PREMIERE DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5900
Practice Address - Country:US
Practice Address - Phone:507-625-9330
Practice Address - Fax:507-625-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN06D38MAOtherBLUE CROSS #
MN06D38MAOtherBLUE CROSS #