Healthcare Provider Details

I. General information

NPI: 1336337526
Provider Name (Legal Business Name): NORTHSIDE MINNESOTA ORAL AND MAXILLOFACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11441 OSAGE ST NW
COON RAPIDS MN
55433
US

IV. Provider business mailing address

11441 OSAGE ST NW
COON RAPIDS MN
55433
US

V. Phone/Fax

Practice location:
  • Phone: 763-862-6442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MOHAMED EL DEEB
Title or Position: DOCTOR/PRESIDENT
Credential:
Phone: 763-862-6442