Provider Demographics
NPI:1821010497
Name:MAXILLOFACIAL AND ORAL SURGERY PA
Entity Type:Organization
Organization Name:MAXILLOFACIAL AND ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:Q
Authorized Official - Last Name:SWIFT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-842-3344
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1405
Mailing Address - Country:US
Mailing Address - Phone:651-842-3344
Mailing Address - Fax:
Practice Address - Street 1:7-174 MOOS TOWER
Practice Address - Street 2:515 DELAWARE STREET SE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55155-0329
Practice Address - Country:US
Practice Address - Phone:651-842-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC00458Medicare UPIN