Provider Demographics
NPI:1679668529
Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:HODAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-722-1854
Mailing Address - Street 1:813 POKEGAMA AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-0349
Mailing Address - Fax:218-326-5005
Practice Address - Street 1:813 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3934
Practice Address - Country:US
Practice Address - Phone:218-722-1854
Practice Address - Fax:218-722-6424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN861461000Medicaid
MNC08159Medicare PIN