Healthcare Provider Details

I. General information

NPI: 1821299041
Provider Name (Legal Business Name): TWIN CITIES ORAL & MAXILLOFACIAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14635 PENNOCK AVE #250
APPLE VALLEY MN
55124-6430
US

IV. Provider business mailing address

925 HIGHWAY 55 STE 202
HASTINGS MN
55033-3734
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-1514
  • Fax:
Mailing address:
  • Phone: 651-437-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY HERDING
Title or Position: OFFICE MANAGER
Credential:
Phone: 952-432-1514