Provider Demographics
NPI:1821299041
Name:TWIN CITIES ORAL & MAXILLOFACIAL SURGERY PA
Entity Type:Organization
Organization Name:TWIN CITIES ORAL & MAXILLOFACIAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-432-1514
Mailing Address - Street 1:925 HIGHWAY 55
Mailing Address - Street 2:STE 202
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-3734
Mailing Address - Country:US
Mailing Address - Phone:651-437-3262
Mailing Address - Fax:
Practice Address - Street 1:14635 PENNOCK AVE
Practice Address - Street 2:#250
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6430
Practice Address - Country:US
Practice Address - Phone:952-432-1514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery