Provider Demographics
NPI:1457401820
Name:NORTHERN ORAL & MAXILLOFACIAL SURGEONS, PA
Entity Type:Organization
Organization Name:NORTHERN ORAL & MAXILLOFACIAL SURGEONS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:BABST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-722-8377
Mailing Address - Street 1:3617 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4046
Mailing Address - Country:US
Mailing Address - Phone:218-722-8377
Mailing Address - Fax:218-722-3117
Practice Address - Street 1:3617 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4046
Practice Address - Country:US
Practice Address - Phone:218-722-8377
Practice Address - Fax:218-722-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24675290011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN60360BAOtherMINNESOTA BCBS CLINIC
WI38393400OtherWISCONSIN MEDICAID CLINIC
MN60360BAOtherMINNESOTA BCBS CLINIC