Healthcare Provider Details

I. General information

NPI: 1245809458
Provider Name (Legal Business Name): NORTHSIDE MINNESOTA ORAL AND MAXILLOFACIAL SURGEONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11441 OSAGE ST NW
COON RAPIDS MN
55433-3677
US

IV. Provider business mailing address

11441 OSAGE ST NW
COON RAPIDS MN
55433-3677
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 Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMED EL DEEB
Title or Position: OWNER
Credential:
Phone: 763-862-6442