Provider Demographics
NPI:1982634010
Name:ORAL & MAXILLOFACIAL SURGERY SPECIALISTS, PA
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY SPECIALISTS, PA
Other - Org Name:OMS SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRBY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-788-9246
Mailing Address - Street 1:550 COUNTY ROAD D
Mailing Address - Street 2:SUITE 12
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-259-9902
Mailing Address - Fax:651-259-9930
Practice Address - Street 1:550 COUNTY ROAD D
Practice Address - Street 2:SUITE 12
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55421
Practice Address - Country:US
Practice Address - Phone:612-788-9246
Practice Address - Fax:612-788-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT93145Medicare UPIN
MNU72794Medicare UPIN
MNC07428Medicare UPIN
MNU72187Medicare UPIN