Healthcare Provider Details

I. General information

NPI: 1407505829
Provider Name (Legal Business Name): FAMILY ORAL SURGERY SPECIALISTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14344 BURNHAVEN DR
BURNSVILLE MN
55306-4928
US

IV. Provider business mailing address

14344 BURNHAVEN DR
BURNSVILLE MN
55306-4928
US

V. Phone/Fax

Practice location:
  • Phone: 612-638-1238
  • Fax: 952-898-4109
Mailing address:
  • Phone: 612-638-1238
  • Fax: 952-898-4109

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: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100