Provider Demographics
NPI:1679620801
Name:AFFILIATED ORAL AND MAXILLOFACIAL SURGEONS P.A.
Entity Type:Organization
Organization Name:AFFILIATED ORAL AND MAXILLOFACIAL SURGEONS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-935-8420
Mailing Address - Street 1:11601 MINNETONKA MILLS RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5161
Mailing Address - Country:US
Mailing Address - Phone:952-935-8420
Mailing Address - Fax:952-935-0147
Practice Address - Street 1:11601 MINNETONKA MILLS RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5161
Practice Address - Country:US
Practice Address - Phone:952-935-8420
Practice Address - Fax:952-935-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN315223500Medicaid
MN352518000Medicaid
MN190000514Medicare ID - Type UnspecifiedDR. CARTER
MN190000247Medicare ID - Type UnspecifiedDR. BLOCK
MNU62508Medicare UPIN
MN352518000Medicaid