Provider Demographics
NPI:1245809458
Name:NORTHSIDE MINNESOTA ORAL AND MAXILLOFACIAL SURGEONS, PLLC
Entity type:Organization
Organization Name:NORTHSIDE MINNESOTA ORAL AND MAXILLOFACIAL SURGEONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:EL DEEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-862-6442
Mailing Address - Street 1:11441 OSAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11441 OSAGE ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3677
Practice Address - Country:US
Practice Address - Phone:763-862-6442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery