MEDICARE: ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679668529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA

Provider Business Mailing Address
First Line	:	303 SE 1ST ST
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3681
Country	:	US
Telephone Number	:	218-326-0349
Fax Number	:	218-326-5005

Provider Business Practice Location Address
First Line	:	303 SE 1ST ST
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3681
Country	:	US
Telephone Number	:	218-326-0349
Fax Number	:	218-326-5005

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	KATHERINE ANNE LAFLEUR
Credential	:	MBA
Telephone Number	:	218-722-1854

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	02/06/2025

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Directions to “ORAL AND MAXILLOFACIAL SURGICAL ASSOCIATES PA ” Practice Location

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