Provider Demographics
NPI:1417034661
Name:MINNESOTA MAXILLOFACIAL AND ORAL CONSULTANTS
Entity type:Organization
Organization Name:MINNESOTA MAXILLOFACIAL AND ORAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-559-7688
Mailing Address - Street 1:15600 36TH AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3369
Mailing Address - Country:US
Mailing Address - Phone:763-559-7688
Mailing Address - Fax:763-559-2237
Practice Address - Street 1:15600 36TH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3369
Practice Address - Country:US
Practice Address - Phone:763-559-7688
Practice Address - Fax:763-559-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND104651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52D13MIOtherBLUE CROSS/BLUE SHIELD
MNU12130Medicare UPIN