Healthcare Provider Details

I. General information

NPI: 1942382379
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 S 6TH ST STE 4
BRAINERD MN
56401-4599
US

IV. Provider business mailing address

1903 SOUTH SIXTH STREET SUITE 4
BRAINERD MN
56401-4599
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-1728
  • Fax: 218-829-1729
Mailing address:
  • Phone: 218-829-1728
  • Fax: 218-829-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM R BAKER
Title or Position: PRESIDENT
Credential:
Phone: 218-829-1728