Healthcare Provider Details

I. General information

NPI: 1134103674
Provider Name (Legal Business Name): SOUTH SUBURBAN ORAL & MAXILLOFACIAL SURGEONS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 EAST NICOLLET BOULEVARD SUITE 205
BURNSVILLE MN
55337-6735
US

IV. Provider business mailing address

625 EAST NICOLLET BOULEVARD SUITE 205
BURNSVILLE MN
55337-6735
US

V. Phone/Fax

Practice location:
  • Phone: 952-435-0310
  • Fax: 952-435-0311
Mailing address:
  • Phone: 952-435-0310
  • Fax: 952-435-0311

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: DR. LAWRENCE A PALMERSHEIM
Title or Position: CEO
Credential: DDS
Phone: 952-435-0310