Provider Demographics
NPI:1720206428
Name:ORAL AND MAXILLOFACIAL SURGICAL CONSULTANTS PA
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGICAL CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KECKHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-841-9658
Mailing Address - Street 1:6350 143RD STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2890
Mailing Address - Country:US
Mailing Address - Phone:952-435-4150
Mailing Address - Fax:952-435-7548
Practice Address - Street 1:7770 DELL ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9316
Practice Address - Country:US
Practice Address - Phone:952-435-4150
Practice Address - Fax:952-435-7548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty